Inspection on 12/02/07 for Magdalen House

This inspection was carried out on 12th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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.

Other inspections for this house

Magdalen House 24/05/06

Magdalen House 25/10/05

Magdalen House 05/05/05

Magdalen House 26/10/04

Magdalen House 22/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Magdalen House Magdalen Square Gorleston Great Yarmouth Norfolk NR31 7BZ Lead Inspector Ann Catterick Unannounced Inspection 12th February 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Magdalen House DS0000034568.V330624.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. Magdalen House DS0000034568.V330624.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Magdalen House Address Magdalen Square Gorleston Great Yarmouth Norfolk NR31 7BZ 01493 661598 01493 444432 ssdmagdalen.house@norfolk.co.uk www.norfolk.gov.uk Norfolk County Council-Community Care 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) Position Vacant Care Home 38 Category(ies) of Dementia - over 65 years of age (38) registration, with number of places Magdalen House DS0000034568.V330624.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That the home should be registered to accommodate older people who have dementia. That the home should be registered to accommodate up to 38 Service Users. 24th May 2006 Date of last inspection Brief Description of the Service: Magdalen House is a care home providing personal care and accommodation for 38 older people who have dementia. The home is owned by Norfolk County Council and is located in a residential area of Gorleston on sea. The fees for the home are £368.72p per week. The home was purpose built some years ago and provides single occupancy accommodation on two floors. There are two passenger lifts serving different areas of the home. The home is in the process of refurbishment and this will improve the environment for service users. Magdalen House has large gardens including a secure area suitable for safe usage for people with dementia. Magdalen House DS0000034568.V330624.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was a key unannounced inspection and took place on the 12th February over a period of 7.5 hours. The inspector was able to speak with service users, relatives, staff and the manager as well as inspect files and documents. A tour of the premises and grounds was also made. Thirty-five service users were accommodated on the day of inspection. Prior to the inspection 10 comment cards were received from service users and five from relatives. An improvement plan had been received from the home identifying how they would address the requirements made at the last inspection. The home has a temporary manager, Chris Chambers, whose management appears to have had a positive impact on the home. All of those staff spoken to said that there had been significant improvements within the home over the past few months. Relatives spoken to on the day of inspection were very positive about the home and service users seen and spoken to either said or appeared to be having their needs met. The quality of care provided within the home has improved significantly due to good management, a revised rota, an improved environment, staffing training and staff commitment to improve the service. The overall quality of the care provided is good. What the service does well: Staff were seen to work with service users in a caring and professional way. All relatives that returned comment cards were satisfied with the care provided. Since the last inspection there have been many improvements and the Local Authority has met in full all except one of the requirements made at the last inspection. The requirement with regard environment has been part met. Lots of improvements have been made and more improvements are to take place in the new financial year. Most of these planned improvements relate to the first floor of the building where minimal work has been done so far. It is also hoped that some work will be done to the safe garden area. Magdalen House DS0000034568.V330624.R01.S.doc Version 5.2 Page 6 Staff, service users and their relatives all spoke positively about the home on the day of the inspection. Comments from service users, relatives and staff are to be found throughout the report. What has improved since the last inspection? The home is being well managed. Care plans have continued to improve and offer all the information needed to ensure staff have the information to care for the physical, health and social needs of service users. Meal times have improved with service users having more choice that includes finger foods. All service users have had their nutritional needs assessed and their weight and general well being is monitored. Information with regard hobbies, interests and past occupations are now on file to enable staff to involve individual service users in what areas interest and enthuse them. The environment in the ground floor of the home has improved very much. The communal area, outside the dining room has been fully refurbished with new furniture fixtures and fittings offering a comfortable and inviting area for service users to sit. Several bedrooms have been re carpeted and decorated. The hallways are now bright inviting areas. Clear signage is all around the home to guide service users to different areas of the home and to empower and inform them. The radiators in the hallway have been covered with domestic covers giving a homely effect. Downstairs toilets have been redecorated and made homely with pictures and dried flowers and bright curtains. The home now has adequate clinical waste bins. Staffing numbers meet the needs of service users. The findings of a quality assurance system have been collated and published. Magdalen House DS0000034568.V330624.R01.S.doc Version 5.2 Page 7 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. Magdalen House DS0000034568.V330624.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 Magdalen House DS0000034568.V330624.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Service User Guide is comprehensive and gives service users and their families the information they need to make an informed choice about whether or not the home would meet their needs and preferences. Prior to admission the home receives assessments from the placing professional as well as completing their own assessment to ensure that the home can meet individual needs. EVIDENCE: The Statement of Purpose and Service User Guide offer all of the information needed to enable informed choice to be made with regard the home. Evidence of this has been seen. Magdalen House DS0000034568.V330624.R01.S.doc Version 5.2 Page 10 Assessments collated prior to admission were seen and it was clear that the home receives information from health and social services workers prior to admission. One service user had moved from another residential establishment and information from the previous placement was seen on file. Also assessment from the community nurse and social worker were also seen. On the day of inspection all of those service users living in the home seemed to be having their assessed needs met. Comment cards received from service users suggested they were not clear about how they were admitted to the home. The home does not provide intermediate care. Comments from service users “I did not know where I was going.” “Can’t recall receiving information.” “Oh yes, I am very well looked after.” Magdalen House DS0000034568.V330624.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, and10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good care plans in place that identify particular health and personal care needs to ensure staff have the information to be able to meet individual needs. Medication practice is now satisfactory and the home provides safe management and administration of medicines. Generally service users were observed being treated with respect and dignity with their privacy upheld. Magdalen House DS0000034568.V330624.R01.S.doc Version 5.2 Page 12 EVIDENCE: Several care plans were seen and there has been a significant improvement since the last inspection. They are much more person centred. For example a service user always had at home three custard cream biscuits with her supper drink and the care plan identified this as one of her needs. A good moving and handling assessment was seen on file for a service user who had particularly complex moving and handling needs and appropriate equipment provided. Care plans include detailed information in an easy to read way. At the beginning of the care plan a photograph and relevant details were listed. This was followed by a comprehensive care plan that looked at several areas of need. Personal care needs were identified, mental well being and comprehension, manual handling needs, medical information, any relevant risk assessments and social history including past and more recent. Care plans included a contract and Service User Guide. They gave information with regard the key worker and care plans were being reviewed on a regular basis. When talking with staff they were now more aware of service users life histories, preferences and aspirations and felt they could talk to service users in a more meaningful way. Nutritional screening has been completed for all service users with those service users deemed as risk being identified and plans of action identified to improve outcomes. Some nutritional plans gave clear evidence of improvement in weight for some service users. This work should be commended. Other health needs were identified within care plans and the home has a good relationship with the community health services. A comment card from the community health worker felt there was still opportunity for improvement but had seen improvements in this area over recent months. Since the last inspection the staff have had more training about caring for service users with dementia and the way staff were seen caring for service users had significantly improved with staff appearing to be sensitive to the rights and choices of the service users. This was evidenced at lunchtime and at other times of the day when staff were engaging with service users. On the 29th September 2006 the Commission issued a Statutory Requirement Notice with regard medication practice. A second visit to monitor compliance with the notice was undertaken by the Commission’s pharmacist inspector on 15th February 2007. He found that since the notice the home has made significant improvement toward demonstrating the safe management and administration of medicines. There is still opportunity for further improvement however the Commission now considers that the Statutory Requirement Notice Magdalen House DS0000034568.V330624.R01.S.doc Version 5.2 Page 13 has been met. A separate report on the inspection of medication has been sent to the registered provider. Some staff were heard to speak to service users using endearing terms such as dear and sweetie. Staff need to ensure this is what service users are happy to be called as not all people enjoy such familiar terms of endearment. A recommendation has been made in this area. The pay phone is placed at the bottom of the stairs and does not offer very much privacy. Service users should be able to have their own phones in their room if they choose. Service user comment “Staff try to do their best for me.” “Staff are lovely.” “I am quite happy with everything.” “You look after me well.” Magdalen House DS0000034568.V330624.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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There has been significant improvement in all aspects of this outcome area since the last inspection and the daily life and social activity has improved for service users. EVIDENCE: Since the last inspection an activities person has been appointed and they are able to spend time with service users identifying interests and offering a range of activity and stimulation. An activities programme was seen on the wall, identifying all that was going on in the home. When the inspector sat with some service users a quiz type questionnaire had been placed on card and were resting on the occasional table. It took only a minute or so for most of the service users around the table to engage in answering the questions and all seemed to enjoy this. A large noughts and crosses game was also on the table for service users to use if they so choose. Staff said that in the afternoons they had more time to spend with service users and all felt that the opportunity to engage in meaningful activity and stimulation had increased. Magdalen House DS0000034568.V330624.R01.S.doc Version 5.2 Page 15 Care plans identified interests and preferences and these could be read with a view to encouraging past interests and hobbies. There was significant improvement in this area. Contact with family and friends is encouraged and supported. One relative who visited the home on most days said that he was always made welcome and made to feel at home. Another relative supported this view on the day of inspection as did comment cards received by relatives and friends. Since the last inspection all staff have received MUST (Malnutrition Universal Screening Tool) training and are all more aware of how to ensure that service users are provided with enough of the right kind of food to encourage a healthy weight and promote wellbeing. On the day of inspection the inspector ate lunch and found it to be appetising and well presented. As well as the two cooked choices there were finger foods, such as eggs, cheese and sandwiches, to offer service users who did not want to eat the main meal or to have as well as the main meal. The lounge diner area upstairs is no longer in use and all service users eat in the main dining room, lounge or bedroom, depending on preference. The dining area was light and spacious with enough staff on duty to assist those service users who needed help at lunchtime. Lunch was relaxed and unhurried. Comments from service users “If your stomach is satisfied, you are satisfied.” “It’s nice here.” “Food not always great.” “Could have more variation.” “I can get up and go to bed when I want.” Comments from relatives “This is much better than where my mother was before.” “I am always made welcome.” Comment from staff “Time to talk to residents.” “Good to have an activities person.” “Nutritional screening has been completed for all service users.” “It is much better now all service users eat downstairs.” Magdalen House DS0000034568.V330624.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure and details of this are contained within the Service User Guide and Statement of Purpose for the home to inform service users and their families how to make a complaint. The home has an Adult Protection Policy and staff are trained in this area. EVIDENCE: The home has a complaint procedure and this is included in the Service User Guide. It is also displayed in the home. There has been one complaint since the last inspection and one complaint is still ongoing. The details of the complaint dealt with were seen and good practice was evidenced with the complainant being satisfied with the outcome. The local authority has robust policies and procedures in place for the protection of vulnerable adults. The policies include a whistle blowing policy that all staff are made aware of through their induction programme and in their staff handbook. Those staff spoken to were clear on what they would do if they witnessed or suspected any form of abuse. There have been no adult protection issues since the last inspection. Magdalen House DS0000034568.V330624.R01.S.doc Version 5.2 Page 17 Comments from service users “I have no complaints at all.” “If I had any complaints I would go to my daughter.” “I think we are treated quite reasonably and I have nothing to complaint about.” Magdalen House DS0000034568.V330624.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Since the last inspection there has been significant improvement in the environment and the refurbishment is planned to continue. When all planned refurbishment is completed the home will provide a comfortable and safe environment for service users to live and this outcome area will be met in full. EVIDENCE: A planned programme for the improvement of Magdalen House has been adopted and significant work has already been completed. The local authority approached Sterling University who have specific knowledge with regard creating an environment that meets the needs of service users with dementia. The outcome is that the colours used for furniture, walls and carpet offer a calm environment with communal and private areas being clearly identified. Magdalen House DS0000034568.V330624.R01.S.doc Version 5.2 Page 19 Most of the downstairs area has been completely refurbished and decorated. The corridor and seating area outside the dining room is now a delightful area for service users to sit. All new carpets and furniture have been purchased and service users were seen sitting in small groups around occasional tables enjoying the environment. The manager has, from amenity funds purchased pictures, soft furnishings and vases for flowers to complete the look and to ensure that it has a homely feel. Within the next financial year the local authority plan to refurbish the upstairs of the home. Fire doors have been fitted to all bedroom doors. The home has a safe garden area but little has been does as yet to enhance it. There is an opportunity to make this a very pleasant and safe outside area for service users. A recommendation has been made in this area. The upstairs dining lounge area is no longer used. The smoking lounge has had glass put in the door to promote safety and ensure the environment can be seen. The windows in the front lounge area were repaired last year and do not let any draught into the lounge area. The temperature in this room is monitored on a regular basis. All of the radiators in the downstairs corridors have been covered with good quality, homely covers that offer protection and are atheistically pleasing. It is hoped wherever possible that the unattractive metal mesh radiators could be replaced by these. A recommendation has been made in this area. All bedroom doors now have signage that is relevant to the occupant. Most had the service users name and a photograph. Other signage was seen within the communal areas of the home that offers clear instruction to service users enabling them to have more understanding of the environment in which they live. An example of this was the clear signs that identified toilet facilities in writing and pictures. Some bedrooms have been decorated and some bedrooms have had their carpets replaced. Further decoration and refurbishment in this area is planned. The downstairs toilets have been refurbished and now have adequate numbers of clinical waste bins. They have also been made to be comfortable and homely by the good use of pictures and vases and new curtains. The toilets on the first floor are small and have no sink in. The sink is in the corridor and not visible when you leave the toilet and is therefore a totally Magdalen House DS0000034568.V330624.R01.S.doc Version 5.2 Page 20 inappropriate facility for the service users. It is believed this is in the plan for refurbishment in the new financial year. Some of the upstairs bedrooms would benefit from redecoration. A requirement has been made in this area. The second lift has now been refurbished and following recommendation by the inspector and advice from Sterling University there is no large mirror in the lift as this could disorientate service users. All areas of the home that service users have access to appeared to be free from hazards on the day of inspection. All areas of the home were clean and tidy, being free from any offensive odours. When talking to domestic staff they felt that where refurbishment had taken place it was much easier to keep the home clean and well presented. Comments from service users “I have my own room, pictures on the wall. I couldn’t be happier.” “I have a key to my door.” Those service users unable to comment appeared happy and relaxed in the newly refurbished lounge area downstairs. Magdalen House DS0000034568.V330624.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There has been improvement in this area and the service users needs are being better met by staff who have or are being trained to meet their needs. Further recruitment has taken place to ensure that service users are cared for by sufficient numbers of competent staff. EVIDENCE: Four new care staff have been appointed since the last inspection and a full time activities worker has also been appointed. The home does still use agency staff but the manager is hoping to appoint his own relief staff. Those staff spoken to all felt that the rota had improved. Shifts now all start and finish at the same time and this has made a more cohesive staff group. Staff appeared to be much calmer and there was less rushing about. There is now additional domestic staff on at weekends and all areas of the home were clean and well cared for. Senior staff have specific roles and responsibilities and this is now working well. On the day of inspection the work completed by the staff involved with training and nutritional screening was seen and the efforts made by these staff should be commended. Nutritional plans were in place for all service users and staff were receiving training in a planned and well-managed way. Magdalen House DS0000034568.V330624.R01.S.doc Version 5.2 Page 22 At the time of inspection 67 of staff had NVQ level 2 or above and all new staff were booked to completed their induction training. The local authority provides safe structures for the recruitment of staff. Staff files contained all of the required documentation need to ensure safe practice in this area. Comments made by service users “Staff are lovely.” “You are always looked after.” “Staff are better on days.” Comment made by staff “Lots better.” “More relaxed.” “Had a good induction.” “Have supervision and staff meetings.” “Rota is better.” “Having lots of managers has been demoralising.” “Came in for training on my day off. Would not have done that six moths ago.” Magdalen House DS0000034568.V330624.R01.S.doc Version 5.2 Page 23 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, 32, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration to the home has improved significantly since the last inspection and this is evidenced in the number of improvements in all outcome areas. The consequence of this is a safer and better quality service is being provided to service users. EVIDENCE: The temporary manager has, with support from other staff working within the home and within the organisation, improved the quality of care provided at the home significantly. Magdalen House DS0000034568.V330624.R01.S.doc Version 5.2 Page 24 The position is at present temporary and he still has some responsibility for the provision he previously managed. It is recommended that whilst at Magdalen House all of his time be spent on this establishment. All staff spoken to spoke positively about the manager saying that he was approachable and his enthusiasm and commitment to the home had had a positive effect on staff and service users. The home has published its Quality Assurance Monitoring results and this is seen as good practice. Any ‘looked after’ money for service users is looked after in a safe way and this was inspected and seen to be in good order with good, safe practice in place. Formal staff supervision takes place on a regular basis and evidence of this was seen on file. All staff receive training in areas of safe working practice, including, moving and handling training, fire safety, first aid, food hygiene and infection control. Hazardous substances are stored safely. Domestic staff need to ensure that they do not leave their mobile domestic workstations unattended. A recommendation has been made in this area. The premises are secure and all appliances and services are serviced on a regular basis. Risk assessments of the environment were carried out last year and this area needs to be revisited. A recommendation has been made in this area. All staff receive induction and foundation training. Comments made by staff “Good manager, very supportive.” “I now have supervision.” “Regular staff meetings.” Magdalen House DS0000034568.V330624.R01.S.doc Version 5.2 Page 25 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 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 3 2 3 x x 3 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 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 x 3 3 x 3 Magdalen House DS0000034568.V330624.R01.S.doc Version 5.2 Page 26 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 OP19 Regulation 23 Requirement That the organisation ensures the second planned phase of the improvement plan for the environment and garden area is fulfilled. Timescale for action 01/04/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP10 OP19 Good Practice Recommendations Staff need to ensure that when speaking to service users using words of endearment, such as dear and sweetie that service users are happy to be addressed in such a way. It would be good practice to cover all radiators in a way that was cosmetically pleasing and homely and not with wire mess. It would be good practice to develop the garden area into a pleasing and comfortable area for service users to use in the warmer weather. Domestic staff need to ensure that they do not leave their mobile domestic workstations unattended as this could be a risk to service users. DS0000034568.V330624.R01.S.doc Version 5.2 Page 27 4 3. OP20 OP38 Magdalen House 4. 5 OP38 OP38 It would be good practice to review the general risk assessments for the home. That it would be good practice for the temporary manager to relinquish any responsibility or commitment to his substantial post whilst working at Magdalen House. Magdalen House DS0000034568.V330624.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Magdalen House DS0000034568.V330624.R01.S.doc Version 5.2 Page 29 - 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. 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