CARE HOMES FOR OLDER PEOPLE
Maris Stella Wing Nazareth House 111 London Road Southend On Sea Essex SS1 1PP Lead Inspector
Mr Trevor Davey Key Unannounced Inspection 19th September 2006 10:30
19 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 Maris Stella Wing DS0000015458.V312825.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. Maris Stella Wing DS0000015458.V312825.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Maris Stella Wing Address Nazareth House 111 London Road Southend On Sea Essex SS1 1PP 01702 345627 01702 430352 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) The Congregation of the Sisters of Nazareth Mrs Christine McCarthy Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Maris Stella Wing DS0000015458.V312825.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. To operate as a care home only. To provide care to 36 older people (OP) over the age of 65 years. Maximum number of registered places 36 (both sexes). 13th January 2006 Date of last inspection Brief Description of the Service: Maris Stella is registered to provide personal care and accommodation for 36 older people over 65 years of age. It is one of two separately registered care facilities sited at Nazareth house, which also has its own chapel, kitchens and laundry. The home is near the town centre at Southend, the railway station, the theatre and all local amenities. The grounds include well-maintained gardens and ample car parking facilities. The premises are older in style and retain many of the characteristics including a large main hall, which is used for activities and entertainment. The home also has its own beach hut at Shoeburyness that residents can use. Accommodation is sited on three floors and there are two shaft lifts. Most bedrooms are single and a limited number have ensuite facilities. There are three lounges, which retain a family home style environment. Additional seating areas are available around the home. Kitchenettes are available on each floor where residents and visitors can make drinks and snacks. The current rate of fees is between £369 and £435 per week. Additional charges are made for hairdressing, chiropody, toiletries and newspapers. Maris Stella Wing DS0000015458.V312825.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The Key Inspection site visit took place over a period of 12 hours. The visit mainly focused on the progress the home had made since the last inspection and covered all Key standards. The Registered Manager and Facilitation and Care Co-ordination Manager were on annual leave. The Responsible Individual for the home, senior care assistants, staff, other health care professionals, residents and relatives were spoken with during the site visit. Their comments and the contributions received were helpful in assisting the Inspector to compile this report. In addition, Case tracking tour place using some of the personal care records and other official records within the home were also assessed. Letters had also been sent out to health care professionals requesting feedback of the service provided by the home. It is understood that the management of the home had conducted a survey with residents and visitors although the responses received was not fully available during the site visit. Overall, feedback, which had been given to the Inspector, was complimentary and positive regarding the standard of care provided. The inspection also took into account previous information submitted by the Registered Manager including the completed pre-inspection questionnaire. What the service does well:
From conversations with residents, relatives and staff as well as feedback from survey forms, which had been returned to the Commission for Social Care Inspection, residents felt safe and well cared for. The staff were said to be kind and polite as well as respecting individual choice and allowing residents to follow their preferred routines for the day. Comments from visitors confirmed that staff were approachable and any concerns which have been raised, are dealt with effectively. Other comments from residents included examples of where their personal mobility had improved and that consistent help is available from the staff team should this be required. Positive comments have also been made regarding the willingness of the staff to liaise and communicate with doctors and that the staff team have a clear understanding of the care needs of residents. Where there have been different views expressed by families, health care professionals and staff regarding on-going
Maris Stella Wing DS0000015458.V312825.R01.S.doc Version 5.2 Page 6 care and support, the management have arranged review meetings with the purpose of agreeing outcomes in a professional and caring way in the interests of residents concerned. Some residents are able to participate in the various social activities including quizzes, flower arranging, music and movement and attending outings for which, the home’s own transport is available. Provision is also made to meet the spiritual needs of residents including services which are regularly attended in the chapel on site. Pre-admission assessment information, and personal care records were clearly set out and included relevant information regarding identified needs and how these should be met. A good variety of alternative food is available for meals, which take into account residents choice. The management of the home have also been good at discussing and sharing with relatives and friends in a recent forum, the proposals for the future. This includes a new residential care home which is to be part of a care village to be developed on the existing site. Aims and objectives, meeting needs of residents as well as the provision of activities were all discussed with a question/answer session. Questionnaires were also given out for people to give their responses. What has improved since the last inspection? What they could do better:
The management need to constantly review staffing levels to ensure that at all times, these relate to the latest assessed needs of residents together with any support which is required. Whilst the focus of care takes into account residents with higher dependency levels, allowances should also be made to enable staff to have sufficient time to communicate with and support other residents whose physical needs may be less demanding. There is a particular shortfall of staffing levels at night, as two awake staff is insufficient to assist residents who need support on a regular basis. This needs to be addressed and account should also be taken of the number of residents in the home and the three different floor levels in the building. Although procedures are in place for the reporting of incidents relating to the prevention of harm to vulnerable adults, these do not accurately reflect the responsibility of the local Social Care Department, which must take the lead for any P.O.V.A. investigations
Maris Stella Wing DS0000015458.V312825.R01.S.doc Version 5.2 Page 7 and subsequent decisions. The management need to clarify the expectations of residents/relatives regarding preferred times of early-morning and late evening routines and the degree of support required. When senior management are on leave, arrangements need to be agreed regarding responsibility for security and accessing personal allowances from the safe on behalf of residents. Where relatives or visitors are not able to assist residents in completing survey questionnaires, staff should be available to give support to residents who are unable to do this unaided. This process should take into account residents who may have a sensory need such as hearing or visionary impairment. 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. Maris Stella Wing DS0000015458.V312825.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 Maris Stella Wing DS0000015458.V312825.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. Pre- admission assessment details for care/health needs had been completed to give staff suitable information to determine whether the needs of potential residents could be met by the home. This judgment has been made using available evidence including a visit to the service. EVIDENCE: Samples of pre-admission assessments were made available for inspection, which included information relating to medical history, communication, sleep patterns, sensory impairments and social history. Other details were completed regarding eating, drinking, behaviour and mobility. As part of this process, the manager visits prospective residents either in their homes or in hospital. From this information an admission care plan had been clearly documented showing activities, sleep, rest and leisure activities as well as dependency rating scales. Care plans had also been compiled assisting new residents to settle in their new home. Residents spoken to who had been
Maris Stella Wing DS0000015458.V312825.R01.S.doc Version 5.2 Page 10 admitted in recent months, confirmed that staff were kind, polite and they were giving the opportunity of exercising choice and following their own preferred daily routines. Relatives who were also in the home at time of the site visit, also confirmed that staff were caring and supportive. The home does not provide intermediate care. Maris Stella Wing DS0000015458.V312825.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. The care, health and medication needs of residents were being met appropriately, which included the involvement of other health care professionals as required. Residents are treated with respect and individual privacy is upheld. Care records were properly maintained but additional information needs to be included in night reports to confirm care needs are fully met. This judgment has been made using available evidence including a visit to the service. EVIDENCE: Case tracking took place in respect of three residents and other personal care records were also looked at, including recent admissions. Residents spoken to were positive and complimentary regarding the assistance staff offered with personal care whilst at the same time, allowing independence to provide selfhelp wherever possible. This included making their own beds and managing some of their own personal care. In some cases, the quality of life for
Maris Stella Wing DS0000015458.V312825.R01.S.doc Version 5.2 Page 12 individual residents had improved since being admitted to the home including better mobility, which gave them more independence. Staff were observed to be interacting sensitively and dealing appropriately with residents who needed reassurance and assistance with mobility. Moving/handling assessments had been completed which included the task and method for assisting residents with manoeuvring into the sitting position, transferring from bed/chair toilet, standing, walking and daily washing/bathing. Risk assessments had also been completed clearly setting out the risk involved, options, effects and the risk reduction action to be taken. These had been completed for a number of areas including mobility, bed rails, the use of wheelchairs and other behavioural or care needs. Evaluation/reviews had also been carried out on a regular basis and dated. Where reviews had been carried out involving the resident, other professionals, family and staff, these had all been properly and clearly documented. Records of treatment provided by community nurses and visits by doctors were available as well as the intervention of physiotherapists, opticians and dental treatment. Other reports were available from the physiotherapist including diagnosis and manoeuvring guidance as well as wheelchair advice from the occupational therapist dealing with safety issues. From the responses received following surveys sent to local doctors, it was confirmed that they were able to see residents in private and that specialist advice had been incorporated into residents’ care plans. There had been a situation where a health care professional did not feel the home had responded appropriately or supportive in rehabilitative care but after a close examination of personal care records, other documentation including correspondence from other health care professionals and discussions with staff, this could not be substantiated. Night reports were inspected which did not give sufficient detail as to assistance provided by staff or the times when this was given. The report book only indicated whether residents were asleep, awake, toileted or had been washed and changed. One of the senior care assists advised the Inspector that the usual times for night checks were 12 p.m., 2 a.m. and 4 a.m. but these times were not indicated. One resident had expressed the wish that they did not wish to be disturbed at night. This situation had not been risk assessed to take into account the welfare and safety of the resident concerned. If this is regarded as appropriate, a form of agreement should be signed by residents concerned and/or families confirming this to be their wish. It was also noted that a number of residents were woken at 6 a.m. with morning tea and it was not clear whether this was always at the request of the residents concerned or part of the routine of the home. Other reports included more detail but did not always show times when assistance was given at night. A random check was made of the night report book entries and it was found that 13,22,15 and 24 occurrences had taken place where night staff were involved with assisting residents on four separate nights. This pattern was consistent for the majority of nights as shown in the home’s records. In addition, the names of two staff had been entered at the end of each night
Maris Stella Wing DS0000015458.V312825.R01.S.doc Version 5.2 Page 13 report but there was no indication as to which member of staff had been involved with the individual residents concerned. Given the number of residents who require assistance at night, this has staffing implications and this matter is covered later in the report under standard O.P. 27. A random check was made of the medication administrative records and entries together with staff signatures had been completed in accordance with agreed practice. Records of medication received were available and photographs had been included as a means to clearly identify residents. Local doctors sign medication records when any change has occurred for prescribed medication. Staff had also attended a course to update themselves on safe medication procedures and practice. Risk assessments and protocols were in place where residents are involved with self-medication. Maris Stella Wing DS0000015458.V312825.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. The home provides an activities/recreational programme to meet preferences, social, cultural and religious needs. Meals take account of residents choice. Relatives and friends are encouraged to have regular contact with the home. This judgment has been made using available evidence including a visit to the service. EVIDENCE: Activity sheets were available showing social functions attended by individual residents. Residents spoken to expressed their own preferences regarding social activities, which they enjoyed and in some cases, residents preferred to spend time in their rooms following their own interests or pastimes. Some residents are able to go out for walks and in the majority of cases, staff or relatives accompany them. Recent outings for residents included visits to parks, places of interest as well as visits to the beach hut, which belongs to the home at Shoeburyness. Social activities within the home include quizzes which are arranged by staff, music and dancing with other small groups of residents choosing to play cards or board games. Residents spoken to also confirmed that staff sometimes take them out to the local shops and visitors are welcome
Maris Stella Wing DS0000015458.V312825.R01.S.doc Version 5.2 Page 15 into the home. The spiritual needs of residents were being met with priests attending residents in their own rooms for communion and a number of residents are able to attend services in the chapel which is on site. The staff team endeavour to spend more time in the afternoons talking to residents but at the time of inspection, there was a vacancy for an activities organiser. The ‘Friends of Nazareth House’ also arrange coffee mornings, strawberry teas and other events every three months. Residents confirmed that they have a choice of meals and attractive, well presented menus were available which included a good variety and choice of meals. Tables were nicely laid with individual serviettes and fresh fruit was available. The teatime menu, which was available on the day of inspection, included a choice of fish fingers, baked beans and chips, salad or cheese on toast. Individual preferences were being catered for and are provided on request. Food was being properly stored and covered in the fridge. A record of meals provided to individual residents was being maintained. Meetings for residents take place and records were available. Some of the residents who attended the meetings said that it is usually the more able residents who attend but because of sensory impairments, not all residents are able to hear or take part. It recommended that the management arrange for staff to spend additional time chatting to individual residents to update information regarding preferences for early morning and late evening routines, social needs, interests and how these can best be met, particularly those with sensory impairments. This would be a positive way of completing survey questionnaires with residents who are unable to do this for themselves and where families may not be involved. Maris Stella Wing DS0000015458.V312825.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. There is an established complaints procedure in place. The homes policy and reporting procedure for the prevention of harm of vulnerable adults is not fully compliant or in line with agreed practice which could put the safety of residents at risk. This judgment has been made using available evidence including a visit to the service. EVIDENCE: The complaints procedure is set out in the Statement of purpose and Service Users Guide. These documents have been made available to residents and copies are in the reception area of the home. There had been no recorded complaints since the last inspection. Residents and relatives spoken to confirmed that the management and staff team were approachable and they were able to raise any concerns, which are listened to and dealt with appropriately. The homes procedure for response to suspected abuse was not compliant with agreed practice and made a distinction between serious incidents when the C.S.C.I. should be informed and the Adult Protection Unit, Southend Social Care Department. The home must follow the laid down reporting procedures, which means that any case of actual or suspected abuse (whether serious or otherwise), must be reported to the various agencies. In addition, the homes policy states that the manager will conduct a thorough investigation into the
Maris Stella Wing DS0000015458.V312825.R01.S.doc Version 5.2 Page 17 incident. This is contrary to the laid down procedure whereby the lead agency for co-ordinating any investigation must be the Adult Protection Unit of Southend Social Care Department. Any subsequent investigation, which the home may feel necessary, can only be carried out after the completion and signing off of the P.O.V.A. process. Staff have attended P.O.V.A. training but not all staff spoken to had a clear awareness of the implications of abuse or their responsibilities to promptly report any suspected or actual incidents which may occur. Maris Stella Wing DS0000015458.V312825.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. The home was clean and hygienic. Ongoing maintenance and servicing of equipment take place to ensure residents can continue to live in a safe and well maintained environment. This judgment has been made using available evidence including a visit to the service. EVIDENCE: The premises of the home were clean and hygienic and residents spoken to, confirmed that their rooms were kept tidy and clean by domestic staff. Rooms had been personalised to accommodate the individual belongings and items belonging to residents. Appropriate furniture, floor coverings, hoisting and lifting equipment was available as required. Records were being maintained of hot water temperatures, which were checked regularly, and warning notices were displayed in bathrooms to ensure hot water was at a safe temperature before bathing residents. Thermometers were provided in bathrooms and on
Maris Stella Wing DS0000015458.V312825.R01.S.doc Version 5.2 Page 19 the day of inspection, the hot water temperature in one area had a reading of 49°. Hot water that was sampled in another bathroom, was hot to the touch although the gardener/handyman regularly carries out checks. Staff should continue to ensure that risk assessments and systems are in place to ensure that hot water temperatures are safe when washing or bathing residents. Maris Stella Wing DS0000015458.V312825.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is adequate. The number of staff on duty together with supervision, was not always sufficient to meet the needs of residents who required assistance at night. Documentation provided with the Pre- inspection questionnaire shows that all staff recruitment records are complete but it was not possible to carry out a random check during the inspection. This judgment has been made using available evidence including a visit to the service. EVIDENCE: Staff rotas were available and the normal provision of staff allows for six care assistants (including senior care assistant) for the early shift and five care assistants (including one senior care assistant) for the late shift. In addition, the manager would cover either the early or late shifts. At the time of inspection, there was a part-time vacancy for an activities organiser. The staffing establishment also allows for two domestics plus laundry assistant. The main kitchen for Nazareth house has its own chef and staff who provide meals for St Josephs and Maris Stella. In addition, staff are available to help prepare and serve meals in the smaller kitchen in Mari Stella. There are two awake staff covering night duty in the home for thirty- three residents on three floor levels. Given the geographical layout of the home and the number of instances which are recorded in the night report where residents require assistance, (see standard O.P.8), a third member of awake night staff should
Maris Stella Wing DS0000015458.V312825.R01.S.doc Version 5.2 Page 21 be provided. This takes into account a number of residents who require the help of two carers and allows for a third person to be available to respond to calls for assistance. Documentation sent with the pre-inspection questionnaire included a list of staff with dates when Criminal Record Bureau checks were completed. It was not possible on this occasion, to have access to the recruitment records in order to check this information and whether other records were complete. Since the site visit, however, a letter of confirmation has been received from the home confirming that two references have been taken up for all staff as well as completed Criminal Record Bureau and P.O.V.A. First checks. These records will be checked at a future inspection. One of the recent staff appointed, confirmed to the Inspector that their C.R.B., two references and proof of identity had been completed before they were recruited. A record of courses and training completed by staff was submitted with the pre-inspection questionnaire. Topics completed included moving and handling, Fire awareness, infection control and safe handling of medicines. Maris Stella Wing DS0000015458.V312825.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 Quality in this outcome area is good. The Responsible Individual, Registered Manager and team, operate the home in the best interests of residents. Staff are properly supervised and measures are in place to ensure the health, safety and welfare of residents at all times. This judgment has been made using available evidence including a visit to the service. EVIDENCE: Good communication systems are in place involving senior management and the staff team. Records of meetings held were available for inspection. Important issues had been identified and acted upon, which included the need for staff to communicate effectively with residents and to see this as an important aspect of caring. Senior care assistants have delegated responsibilities involving medication, risk assessments, and supervision.
Maris Stella Wing DS0000015458.V312825.R01.S.doc Version 5.2 Page 23 The Pre-inspection questionnaire submitted by the home, gives details of the dates when equipment and services have been inspected. This includes gas installations, electrical wiring certificate, hoists and mechanical aids as well as a health and safety visit. Records were also available of fire equipment checks, lectures and fire drills. Records of transactions and receipts were available in respect of the personal allowances safeguarded by the home. It is recommended that arrangements be made by the management for access to be made available to the safe in the absence of the manager, to ensure residents can have access to their allowances when required. A response from one of the survey questionnaires completed by a resident, indicated that the quality of care, friendliness of staff was good and the support of the home and cleanliness was excellent. Regular monitoring inspections of the home are undertaken by the Responsible Individual and reports are submitted to the Commission for Social Care Inspection as required by Regulation 26 of the Care Homes Regulations. Maris Stella Wing DS0000015458.V312825.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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 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 2 3 x x x x x x 3 STAFFING Standard No Score 27 2 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 Maris Stella Wing DS0000015458.V312825.R01.S.doc Version 5.2 Page 25 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. 1. Standard OP8 17(Sched. 3) Requirement The Registered Person shall maintain in respect of each service user and keep up-todate, records and times of any treatment or care provided. This refers specifically to night reports. The Registered Person shall make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. This refers specifically to the home’s policy and reporting procedure which must be compliant with the Public Interest Disclosure Act 1998 and Department of Health guidance No Secrets. The Registered Person shall, having regard to the size of the care home, and the number & needs of residents, ensure that at all times, suitably qualified, competent & experienced persons are working at the care home in such numbers so as to meet the health & welfare of service users. This relates
DS0000015458.V312825.R01.S.doc Timescale for action 20/10/06 2. OP18 13(6) 20/10/06 3. OP27 18 01/11/06 Maris Stella Wing Version 5.2 Page 26 specifically to the needs of residents at night where three awake staff must be made available. 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. Refer to Standard OP12 Good Practice Recommendations The Registered Provider should arrange for residents and/or relatives to be consulted regarding preferred early morning & late evening routines, as well as establishing updated information regarding social interests. The Registered Provider should continue to review risk assessments to ensure hot water temperatures are safe for residents. The Registered Provider should make alternative arrangements for security of the safe when the manager is absent, to ensure service users can have access to their personal allowances when required. 2. 3. OP19 OP35 Maris Stella Wing DS0000015458.V312825.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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