Inspection on 11/07/08 for Marie Louise House

This inspection was carried out on 11th July 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.

Other inspections for this house

Marie Louise House 12/07/07

Marie Louise House 16/05/06

Marie Louise House 10/01/06

Marie Louise House 09/08/05

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Marie Louise House Newton Lane Romsey Hampshire SO51 8GZ Lead Inspector Kathryn Kirk Unannounced Inspection 11th July 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 Marie Louise House DS0000062154.V367569.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. Marie Louise House DS0000062154.V367569.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marie Louise House Address Newton Lane Romsey Hampshire SO51 8GZ 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) 01794 521224 01794 526310 The Hospital Management Trust Mrs Kay Wendy Kelly Care Home 46 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (10), Old age, not falling within any other of places category (46), Physical disability (10), Physical disability over 65 years of age (10) Marie Louise House DS0000062154.V367569.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All service users must be over the age of 60 years. Date of last inspection 12th July 2007 Brief Description of the Service: Marie Louise House is a home for up to forty-six people. The home is owned by a registered charity, the Hospital Management Trust. The home has been built on the site that previously occupied by La Sagesse school. The building has been designed to provide the service users with single ensuite accommodation and has been decorated and furnished to a very high standard. The gardens have been landscaped and provide areas of privacy for service users to sit. The home places emphasis on the pastoral care that is provided by the Sisters of Wisdom who live in the convent alongside the home. Service users of all denominations are accommodated in the home. The home has a large car parking area and is within walking distance of Romsey town centre. Current fees range from £771 per week on Kingfisher and Skylark floors and from £900 per week on Nightingale Floor for residents requiring closer supervision. Marie Louise House DS0000062154.V367569.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Evidence for this key unannounced inspection was gathered from the following sources: The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Seven surveys returned to us by people using the service and ten from staff members. The previous key inspection which took place in July 2007 A visit to the home on 11 July 2008, which lasted for 6 hours. The needs of some of the service users are such that they were unable to contribute verbally to the inspection process. Time was therefore spent in their company and by observing interactions between them and staff in the commmunal areas. Six service user gave their views about the service as did seven staff and three visitors. All communal areas and some bedrooms were seen. Time was spent with the manager and some administrative records were viewed. What the service does well: People spoken with said that they felt safe and comfortable at Marie Louise House. Most other comments were positive, for example people said, “Staff are marvellous” “they do enough but not too much,” “perfect,” “nothing wrong here,” “the food is really good” Good information about the home is provided to people in the statement of purpose and residents’ guide. This helps people to make an informed choice about whether Marie Louise House is right for them. There is a good range of activities provided and the service has a dedicated activities co-ordinator. Staff have time to escort people to the shops or for walks in the garden and local area. Marie Louise House DS0000062154.V367569.R01.S.doc Version 5.2 Page 6 Pastoral care is provided by a sister from La Sagesse Convent who own the home. However the home is prepared to meet the spiritual needs of people from any denomination or religion. For some people this religious link plays a part in their decision to live at the home. Food is of a high quality and is attractively presented. Peoples’ preferences and wishes are considered when menus are devised. There are a number of water cooling machines in communal areas so residents have access to plenty of cold drinks at all times. The staff at the home are conscientious about infection control and facilities for hand washing are available throughout the home. This promotes the health and well-being of the people in the home and reduces the spread of infections. A good range of training opportunities are available to staff. Staff have a friendly and respectful relationship with residents. A particular strength of the home is the high level of quality assurance that is undertaken. This means that staff are continuously reviewing and evaluating the practices and policies that inform the care that is given and it helps to ensure that people’s different and changing needs and wishes are at the heart of the service. What has improved since the last inspection? What they could do better: The recruitment of more permanent staff may improve consistency of care to residents. The manager has agreed to refresh her knowledge of the Adult Protection reporting procedures. Staff should increase their knowledge of the Mental Capacity Act as it could affect the lives of some people in their care. This is already in the process of being arranged. Marie Louise House DS0000062154.V367569.R01.S.doc Version 5.2 Page 7 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. Marie Louise House DS0000062154.V367569.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 Marie Louise House DS0000062154.V367569.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, Intermediate care is not provided so standard 6 does not apply Quality in this outcome area is good. People are given accurate information about the home and their needs are understood before they move in. This helps to ensure that the service can provide the appropriate level of care and support. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Prospective residents and their families are given a comprehensive residents guide, which gives good information about the service provided. They are also given a copy of the statement of purpose, which informs them of staffing arrangement and policies and procedures of the home. All people spoken with confirmed that they had sufficient information before they moved in to ensure that the service was right for them and this was endorsed by all people who completed written surveys. Marie Louise House DS0000062154.V367569.R01.S.doc Version 5.2 Page 10 The annual quality assurance assessment says that the service undertakes an assessment, which is completed by either the Matron or the Deputy Matron prior to admission. The assessment tool used assesses the prospective resident’s nursing and personal care needs. The AQAA says “This process involves the families when appropriate and we liaise with any multi disciplinary team member involved in the prospective resident’s care.” The files of two service users who had been admitted since the last inspection were viewed during the visit. Both contained detailed information, which had been obtained before they moved to Marie Louise House. This covered all aspects of their care, medical and social needs. One person also had an assessment on file that had been completed by a care manager and there was additional information provided by health care professionals. The information provided in the AQAA was therefore found to be accurate. Intermediate care is not provided, so standard 6 has not been assessed. Marie Louise House DS0000062154.V367569.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good Care plans are clear and accurate. This helps staff to respond effectively to each individuals need. Service users rights to privacy and dignity are always observed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the last inspection, care planning was found to have improved, however two requirements were made. These were that plans must contain enough detail for staff unfamiliar with the person to be able to support them successfully and that care plans must be updated as the persons needs change. Since this time the manager said that staff have worked hard to improve care plans further. The AQAA states Marie Louise House DS0000062154.V367569.R01.S.doc Version 5.2 Page 12 All residents have a comprehensive care plan designed to be individual and to express their needs and rights for the best outcome. • Residents with different levels of needs such as specialist nursing have specific care plans written to ensure that all their care is fully met and clearly documented. • A daily routine form is completed by a carer with the resident and/or representative shortly after admission and is evaluated when appropriate to ensure that the resident’s choose their daily routine and it is what they want. The manager said that residents and relatives are encouraged to get involved with the planning of their care. On the day of the visit, time was spent talking to one resident about his care and talking with relatives of another resident and observing how staff responded to need. Care plans and information about daily routines were viewed. These appeared to be accurate and to reflect peoples’ needs and wishes. In addition a number of tools are completed to monitor health, for example, nutritional assessment and Waterlow Index. Risks had been identified and people have moving and handling assessments to ensure that staff can support them appropriately and to minimise the risk of falls. Care plans seen had been signed by the service user or their representatives to indicate that they agreed with what had been said. All seen had also been updated monthly. Staff were also given clear written instructions when there was a need, on how to communicate with people. Staff who were surveyed were asked “are you given up to date information about the needs of people you support or care for” and generally said that they were. This was endorsed by staff spoken with during the visit. Some care staff pointed out however that they did not always have access to records held on computer. All people surveyed felt that they received the care and support they need Comments included “the care is very good indeed” “I’m impressed by the care and attention my mother receives” Records showed that appointments are kept to see specialist health care professionals for example, opticians and dentists. Residents said that doctors visit the home regularly and all who answered the survey felt that they always received the medical support that they need. There are procedures in place for the safe management of medicines. The manager said that two current service users take their own medication. Risk assessments have been completed to ensure that this happens safely and they have been provided with their own lockable storage facilities so that their medicine can be appropriately stored. • Marie Louise House DS0000062154.V367569.R01.S.doc Version 5.2 Page 13 Records of medications checked were properly completed. All people spoken with felt that staff respect their privacy and dignity. During the visit staff were observed to talk with people in a friendly and respectful way. All rooms at Marie Louise House are single and en-suite. Marie Louise House DS0000062154.V367569.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 excellent Attention is paid to ensure that service users are given as much choice as possible in their daily lives and that the social activities provided match their interests. Visitors are made very welcome. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information about peoples’ interests are included in peoples’ care plans. On the day of inspection the activities co-ordinator, who is employed full time was observed to be talking with one service users family to find out more information about his life and interests. This was important as the service user was unable to convey this information for themselves and it would help staff to communicate more effectively with him. The manager said that each week an activity schedule is circulated to everyone and one is displayed in the notice board. The activities co-ordinator visits everyone after lunch to invite them to the activity of the day. People asked on the day of the visit said that they were happy with activities on offer, and were able if they wished to go out with staff support. People felt Marie Louise House DS0000062154.V367569.R01.S.doc Version 5.2 Page 15 that they were able to continue with their hobbies and interests and this view was echoed by people surveyed. The activity co-ordinator was praised by one visitor, who described her as “marvellous” The home is owned by a Roman Catholic religious order, the Sisters of the Daughters of Wisdom and managed by an organisation based on Christian principles, the Hospital Management Trust. One of the sisters from La Sagesse convent next door provides pastoral care for the home and meets those living there on a one-to-one basis if they wish. Although the home is grounded in a Christian ethos, people of any denomination or religion are welcome to live there. Currently Roman Catholic and Anglican services are held at the home, but other religions and denominations would be provided for upon request. The Christian presence is not overt and those living there and the staff follow their own particular religious persuasion, or none, if they wish. The residents guide says that visitors are welcome at any time. Visitors spoken with during the visit said that this was the case and confirmed that they could visit their relative in private if they wished. Rooms seen were furnished and decorated with service users possessions Care plans contained information about people’s preferred daily routines. Service users spoken with felt that they could still exercise choice in their daily lives and one person said of the staff “they do enough but not too much”. The AQAA says • Meal times are a social occasion in the dining room. The people who use our service are encouraged to invite relatives/friends for lunch on any day they wish. Wine or sherry is available at each lunchtime. • A varied and well balanced diet is offered and any request is obliged by the catering staff. All dietary needs are met. • Snacks are placed in the lounge of the closer supervision unit in the afternoon to encourage hand dexterity and for the sufferers of Dementia as on occasion meals are not eaten and this helps nutrition to be maintained. • The kitchenettes are always well stocked with fresh fruit and other food so people who use our service are able to have something to eat whenever they feel hungry. Fresh sandwiches are made to be offered with the bedtime drink. A variety of drinks are available throughout the 24 hour period of a day and any requests will be implemented. This was substantiated through observation and discussion with staff and service users. Comments from surveys included “our likes and dislikes are acted upon.the meals are excellent” “We see the menu the day before and can choose from options available” “the food is plentiful and beautifully served” Marie Louise House DS0000062154.V367569.R01.S.doc Version 5.2 Page 16 The service also monitors peoples’ views of the catering in their own quality assurance survey. (Most recently conducted November 2007) Marie Louise House DS0000062154.V367569.R01.S.doc Version 5.2 Page 17 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 People can complain and they will be listened to. Action is taken to ensure that residents are protected although this could be improved by ensuring that reporting procedures are always correctly followed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is information about how to make a complaint in the residents’ guide Surveys showed that people know how to make a complaint and are confident that any concern would be listened to and acted upon. Most staff surveyed said that they knew what to do if a service user, relative or advocate had concerns about the home. However two said they did not. Most relatives surveyed in the services own questionnaire were happy with the response made to complaints Records of complaints seen showed that they had been responded to quickly. A great number of complementary letters and cards were also seen. One complaint seen which had been made some time ago should have been referred to the local adult service department under adult protection procedures. This was discussed with the manager at the time of the visit. It was evident that the manager had however taken action to protect the service user concerned and that she had informed relatives. Policies and procedures are in place to ensure that service users are protected from abuse. These include a whistle blowing policy that advises staff on how to Marie Louise House DS0000062154.V367569.R01.S.doc Version 5.2 Page 18 report concerns. The AQAA says that all staff have attended training in adult protection matters and staff spoken with confirmed this. The manager agreed to look again at adult protection processes to ensure that she follows correct procedures in reporting any alleged abuse should the need arise in future. Marie Louise House DS0000062154.V367569.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is excellent The living environment is appropriate for the particular lifestyle and needs of the residents and is clean, safe and comfortable, This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was purpose built and opened in May 2005. It is in a good state of repair and has a full time handyman employed to maintain it. All bedrooms have an en suite toilet and washbasin. Three also have a shower. Five specialist baths are available in the home for those who require assistance getting into and out of the bath and/or in the bath. In the services own survey of November 2007 most people rated the standard of their bedroom/bathroom as either excellent or good, although a couple of people said that they would like more storage space. People spoken with Marie Louise House DS0000062154.V367569.R01.S.doc Version 5.2 Page 20 during the visit all said that the environment was safe and comfortable. Some commented on the lovely views that could be seen out of all the large windows. One person said “I appreciate the fact that there are in effect two lounges on each floor” another said, “This is a beautiful place” There is a large dining room on the ground floor adjacent to the kitchen, where those who wish can eat lunch. There is a small oratory for quiet and prayer. Doors from the ground floor lounge and dining rooms open onto the garden. There is a paved area immediately in front of the house. There is an area of lawn and then a wild flower meadow/nature garden belonging to the convent, but providing a pleasant outlook for the home. Marie Louise House was awarded an excellent rating at the most recent food hygiene inspection in December 2007. There are a number of cooled water dispensers in communal areas and staff were observed to ask residents regularly whether they wished to have a drink. The services own survey reflected that in general, people were happy with the laundry service provided. All people who responded to the CSCI survey said that the home was always fresh and clean and one service user praised the domestic staff saying that they were “worth their weight in gold” The standard relating to hygiene and the control of infection was found to be good in the previous inspection of 2007. Since then further improvements have been made: The AQAA says “The home has increased the number of non touch hand towel dispensers to help reduce cross infection and also increased the number of alcohol gel dispensers throughout the home”. This was verified during the visit. Staff were observed to be using the alcohol gel regularly. Staff confirmed that disposable gloves continued to be available in all rooms to promote infection control Marie Louise House DS0000062154.V367569.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 The people living at Marie Louise House benefit from a well trained, caring staff team. The service would benefit from employing more permanent staff rather than engaging agency workers. The homes recruitment policy and practice supports and protects service users This judgement has been made using available evidence including a visit to this service. EVIDENCE: In the services own survey people were generally very satisfied with the standard of staff employed. In the CSCI survey people mainly felt that staff listen and acted upon what they said and said that there were usually or always staff available when they needed them. All residents spoken with during the visit spoke positively about the staff “they are marvellous” “very caring” “they all work very hard” although some commented that there were a large number of agency staff employed and that sometimes they did not respond as well as permanent staff members did. Staff who were spoken with and were surveyed, generally felt that there were enough staff on duty to meet individual needs of all the people who use the service, although some also commented that there are a large number of agency workers which sometimes unsettled the residents. Marie Louise House DS0000062154.V367569.R01.S.doc Version 5.2 Page 22 The management team have identified this as an issue and in the AQAA state that they could improve the service by reducing the amount of agency staff used by the service. Forty-five nursing and four hundred and ten care shifts have been covered by agency staff over the past three months. The high number of agency staff was also discussed in the last inspection report. The manager said that she has tried to improve consistency by using only one agency for care staff and nurses respectively and that she has undertaken a recruitment drive to try to fill permanent posts. Most staff surveyed and spoken with felt that they had the right support experience and knowledge to meet the different needs of people who use the service. Some staff spoken with felt that morale was low. It has been identified as part of the homes own survey that staff did not always feel that they were recognised for good work. This was being addressed with management. The AQAA shows that thirteen out of twenty two staff currently have completed an National Vocational Qualification (NVQ) to level 2 or above in care, and that four staff are working towards this qualification. This is above the minimum of 50 recommended in the National Minimum Standards for Older People. At the last inspection a requirement was made that “Thorough preemployment checks, such as obtaining references and complete employment histories, must be carried out to safeguard the people in the home from people who may not be suitable to work with them”. Recently recruited staff spoken with during the visit said that they felt that the recruitment process was thorough. The AQAA confirms that all staff employed within the last twelve months have completed satisfactory recruitment checks. Two records of recent employees were checked during the visit, these included two satisfactory written references, evidence of identity, a copy of terms and conditions of employment, job description and a completed application form with a full employment history. The manager confirmed that all details of completed Criminal Record Bureau checks were held on computer. The requirement made at the last inspection has therefore been met. New staff spoken with felt that their induction training had been thorough and the manager said that new staff are allocated a trained nurse to support them and that they spend a minimum of a week learning their job, or longer if necessary. This depends on their confidence and skills. Staff surveyed and spoken with all felt that they are given relevant training and that it helps them to understand and meet the needs of individual service users. Comments included “I have had the most training here that I have had in any job. It is really good” “the training at Marie Louise House is excellent, every member of staff is encouraged to take up a course.” The home uses an Marie Louise House DS0000062154.V367569.R01.S.doc Version 5.2 Page 23 e-learning system where staff can access a training programme via the Internet. Staff records seen showed that staff had received training in both mandatory areas, such as infection control and moving and handling and had also completed training in subjects such a Alzheimer’s, dealing with challenging behaviour and caring for people affected by stroke. The manager said that there is a training matrix to ensure that staff are kept up to date on all mandatory courses. The manager said that senior staff are going to undertake training on the Mental Capacity Act. Marie Louise House DS0000062154.V367569.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good The home is managed in the best interest of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is Mrs Kay Kelly. She is a first level registered nurse with many years experience in nursing. Staff were asked do the ways you pass information about people who use the services between staff (including the manager) work well” nearly all answered “always” or “usually” to this question One person said “I get 100 support from the manager, her door is always open” Other staff during the visit said that they saw the manager less but said that the deputy manager was around “on the floor” very regularly and so could see how the service is working and offer support. Marie Louise House DS0000062154.V367569.R01.S.doc Version 5.2 Page 25 The Hospital Management Trust has a quality assurance programme that is followed in all its homes. This involves an annual survey of the people living in the home, and of its staff, which is sent out and returned to the organisation’s headquarters. The results are analysed and a report sent to the home. The results of the two most recent surveys conducted in November 2007 were seen. They showed that most people were happy with the quality of service provided and any areas which could be improved had been identified. The service also has a questionnaire to give people the opportunity to express their views about the quality of food provided at the home. The home has monthly management meetings involving the Director of Care Homes and the Financial Director from the Hospital Management Trust, and the Manager and financial Administrator from the home. They develop and monitor the annual business plan. There is a system in place to support those people who do not look after their own money. The financial administrator manages this and keeps records of deposits and withdrawals. The records and amounts held were looked at for two residents. These were accurate and had been signed to confirm that they were correct by the residents’ representatives. At the last inspection a requirement was made that the manager must ensure staff receive formal supervision by an appropriately trained line manager. This related specifically to nurses. The AQAA confirms, “all care and nursing staff have a clear programme of supervision 6 times a year.” Staff spoken with during the visit agreed that they now received supervision so this requirement has been met. The annual quality assurance assessment shows that policies and procedures relating to health and safety matters are in place and have been reviewed and updated regularly. These include fire safety, first aid, hygiene and food safety, health and safety and control of substances hazardous to health (COSHH). Records also show that gas appliances, fire detection and fighting equipment, lifts and hoists and emergency call equipment have all been serviced or tested within the last year. Marie Louise House DS0000062154.V367569.R01.S.doc Version 5.2 Page 26 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 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 X X X X X X 4 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 Marie Louise House DS0000062154.V367569.R01.S.doc Version 5.2 Page 27 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. 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 Marie Louise House DS0000062154.V367569.R01.S.doc Version 5.2 Page 28 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 Marie Louise House DS0000062154.V367569.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!