Inspection on 28/06/07 for Mary Chapman Court

This inspection was carried out on 28th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Mary Chapman Court 24/10/08

Mary Chapman Court 05/07/06

Mary Chapman Court 18/08/05

Mary Chapman Court 01/04/05

Mary Chapman Court 09/11/04

Mary Chapman Court 20/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Mary Chapman Court Mary Chapman Close Dussindale Norwich Norfolk NR7 0UD Lead Inspector Mr Jerry Crehan Unannounced Inspection 28th June 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 Mary Chapman Court DS0000044397.V345050.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. Mary Chapman Court DS0000044397.V345050.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mary Chapman Court Address Mary Chapman Close Dussindale Norwich Norfolk NR7 0UD 01603 701188 01603 436848 marychapman@schealthcare.co.uk thewoodland@schealthcare.co.uk Southern Cross Healthcare Ltd 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 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Mary Chapman Court DS0000044397.V345050.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to thirty-four (34) Older People, not falling into any other category, may be accommodated. 5th July 2006 Date of last inspection Brief Description of the Service: Purpose built in 1997, Mary Chapman Court is located in a residential area on the outskirts of Norwich in Thorpe St Andrew. The home can accommodate 34 older people in 28 single (26 with en-suite) and three double rooms (1 with en-suite). The accommodation is on the ground and first floors. The first floor can be accessed by passenger lift. The surrounding lawns and garden areas are well maintained and can be accessed by service users. There is ample parking space at the front and to the rear of the premises. The local GP practices, and other health professionals support the home. The range of fees charged is £350 - £450 per week Mary Chapman Court DS0000044397.V345050.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups which assess how well a provider delivers the service to people. The key inspection has been carried out by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This report gives a brief overview of the service and the current judgments for each outcome group. This home was acquired by new providers Southern Cross Healthcare Ltd from Alpha Care Services UK Ltd in December 2006. A new manager was appointed in March 2007 and has yet to submit an application for registration with the CSCI. The registration process for the change of ownership is not yet complete. The key inspection took place over 9 hours on the 28th June 2007. A brief tour of the premises was undertaken as well as looking at records and procedures and talking to staff and residents about the service the home provides. Five comment cards from residents and eight from relatives out of a total of twenty were returned to the Commission. The comments overall were favourable about the service and acknowledged that there have been a number of improvements since the change of ownership. One resident said that the care they receive is good and another said that they are very happy with the support they receive. Other comments were less positive stating that the management and staff need to improve on personal service to residents, so that it is consistent. One comment card said that they thought some of the meals bland and would like to see more fresh fruit and fresh fish dishes on the menu, another said that given the fee levels the meals provided at times were not in their view ‘value for money’. The manager provided pre inspection information using the new Annual Quality Assurance Self Assessment form. It was agreed that the information provided through the form was minimal and would have benefited from more particular evidence of practice and details of the service. The manager acknowledged that this had been a first experience of the using the format and had not directly used all of the CSCI guidance issued with the form. What the service does well: There is good basic information about the company and the home available to prospective service users. Residents and staff confirmed that improvements are being made in the quality of the service and more so since the appointment of the new manager. Mary Chapman Court DS0000044397.V345050.R01.S.doc Version 5.2 Page 6 There is evidence of improvements in the décor and general maintenance of the home. People visiting the home confirmed that they are made welcome and that staff are helpful and friendly when they visit the home. There is evidence that the training opportunities for staff to achieve NVQ accreditation is now being established with formal registration taking place on 26 July 2007. What has improved since the last inspection? What they could do better: The service needs to provide prospective residents with an updated Service Users Guide and Statement of Purpose that includes detailed information on how to make a complaint. The service should find ways in which residents are socially stimulated and their personal interests encouraged and developed. The service should also ensure that residents can access a range of recreational activities both on site and within the local community. The management needs to re-establish the quality audit processes for promoting and developing the service; including, seeking the views of the residents and staff and publishing the quality survey outcome and any agreed action. Establishing formal and direct supervision and appraisal processes for staff that will evaluate their development and monitor professional practice. Through direct management, continue to improve the service delivery and maintain consistent care practice. Mary Chapman Court DS0000044397.V345050.R01.S.doc Version 5.2 Page 7 Recruit and retain suitably experienced / qualified staff to meet resident’s health care and emotional and social needs and ensure that there are sufficient numbers of staff on duty at all times to provide both care and domestic support. The management should review and replenish where necessary tableware, cutlery, crockery, glass and linens, and monitor the standard of presentation for the serving of meals Establish a management structure within the home where areas of responsibility and monitoring of the service can be delegated to senior staff with the skills and expertise to carry out the designated tasks. The manager should submit an application to register with the Commission for Social Care Inspection 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. Mary Chapman Court DS0000044397.V345050.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 Mary Chapman Court DS0000044397.V345050.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): Standards 1,3,6 People who use the service experience adequate quality outcomes in this area. This judgement has been made using a range of evidence, including a visit to the service. People using this service cannot currently access detailed information about the home that will assist them to make an informed choice about where they wish to live. Good assessment processes are in place and new residents are only admitted to the home on the basis of a full assessment of need to ensure their individual needs can be met. There is no separate rehabilitation service provision in this home. EVIDENCE: The home provides prospective residents with a general brochure about the company and a brief description of the service for the home, but the brochure lacks precise detail about the home so that prospective residents or their representatives can make an informed choice about where they wish to live. The manager has made relevant changes to the Service Users Guide and Mary Chapman Court DS0000044397.V345050.R01.S.doc Version 5.2 Page 10 Statement of Purpose for the home but updated copies have not yet been issued by the company. See requirement. The home has a good pre admission format and all the current care plans have been updated by the manager to include a revised assessment of need and risk assessment for each resident. Four files were seen during the course of the inspection and provide clear information about the need healthcare needs for each person. The home does not have a separate intermediate service but does provide respite care as part of supporting people in the community and as an introduction to longer -term care. Mary Chapman Court DS0000044397.V345050.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): 7,8,10 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence, including a visit to the service. Residents receive good standards of care based on their assessment of need. There is also evidence to show that residents are treated in a dignified way and their personal wishes and choices respected. EVIDENCE: An unannounced pharmacy inspection was carried out by the Pharmacist Inspector Mark Andrews on 18th May 2007. The inspection included audits of current and previous records relating to the receipt, administration, and disposal of medicines. The outcome was judged to be adequate. Three requirements and two recommendations to improve general practice and administration and training were made and a separate report sent to the providers. A copy of this report can be made available to the general public on request. This standard was not inspected again at the key inspection carried out on 28th June. Staff responsible for the management of medication are attending updates and refresher sessions carried out by the Alliance Pharmacy Training group. Mary Chapman Court DS0000044397.V345050.R01.S.doc Version 5.2 Page 12 The comments from relatives and residents through the survey cards are mixed but overall the service offered is satisfactory. One complaint has been raised recently with the manager with regard to the quality of care being offered. The manager confirmed that the investigation is now complete and a response and report has been prepared for the resident’s representative. Relatives responding through the comment cards feel that staff ‘are doing their best’ but the recent changes in ownership and management has caused ‘changes in the staff numbers and abilities’. A small number of relatives comments refer to insufficient numbers of staff to meet resident’s personal healthcare needs either because of sudden absences from work or shortages of staff, and want to see an increase in the number of staff on duty throughout the day. One resident is being treated for an open wound that is healing appropriately. The staff are following all the advice and recommendations made by the visiting health care professionals to promote good mobility and skin tone. One resident said that the staff are ‘always helpful and kind’ and can be relied upon to respond to calls and personal needs of each person as quickly as possible. Another said sometimes staff are difficult to understand because English is not their first language and some residents have a hearing problem. One relative commented that the care overall is satisfactory but sometimes the standard of cleanliness in their relatives room is poor with sticky surfaces and dried food on the carpet, which is not always noticed and attended to. One resident said that the quality of service has improved in the last few months and that the staff seem to be ‘better at their jobs’ and feels confident that things will continue to improve. All the residents spoken to on the day said that the staff treat them with respect and are always considerate and kind. The manager acknowledged that she is working towards stabilising the staff team and also creating a more clearly defined managerial structure for the home. It is agreed that there is work to be done in monitoring practice and to ensure they achieve a good standard of care. The manager has introduced an accountability chart for each residents room and the staff attending to the needs of the resident must complete the chart so that assessed care needs especially those unable to comment about their own care can be monitored. The manager confirmed that each care plan has been revised and updated in the last three months using the new company format. There are twelve sections to each plan of care that relates to individual or specialist need including a completed risk assessment for falls and use of aids and equipment. Four care plans were seen during the course of the day and each offered a brief picture of the person and their healthcare needs. The manager is also seeking additional information about people’s social and recreational interests. Mary Chapman Court DS0000044397.V345050.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14,15, People who use the service experience adequate quality outcomes in this area. This judgement has been made using a range of evidence, including a visit to the service. The social and recreational activities provided at this home fail to meet the needs and expectations of the residents. EVIDENCE: There are no formal activities or social stimulation for residents in place. Staff were observed chatting and spending brief time with residents during the day of the inspection but this is usually an ad hoc arrangement and staff spoken to on the day confirmed that they do try to give some personal time to residents other than when they are providing support or care. Other times one of the care staff will organise a group activity, but again this is an ad hoc arrangement. From the comment cards received both relatives and residents said that they would like to see more social stimulation and activities taking place. One of the residents said that they have a very good library service visiting the home that she uses on a regular basis. A separate post of activities coordinator( 25hrs per week) has been created and is being advertised. The manager is also in consultation with one of the residents in the home who has previous experience and knowledge of promoting and organising social events and activities. See requirement. Mary Chapman Court DS0000044397.V345050.R01.S.doc Version 5.2 Page 14 Residents spoken to on the day said that they are able to live their lives they way they want to given their own limitations. The staff said that they try to be flexible with routines and care support and respect people’s choices and options. Residents are encouraged to maintain contact with their friends and family and are welcomed into the home when they visit. There were mixed comments from residents and relatives about the menus and meal choices. Some saying that the range and options of meals is good others said that they would like to see a wider choice of fresh fish and fruit. The manager confirmed that there is a new chef in post with appropriate catering qualifications, who is promoting more home made dishes and resident choices. The manager said that this area of the service is under review and changes are being planned to improve the menus in line with the company’s own catering system. The ‘nutmeg’ system offers a range of designed menus that are nutritionally balanced and also provide suggested recipes, and evaluate the cost. Menu boards are situated in the dining rooms but they are not well placed and the information unclear. During the brief tour of the premises it was acknowledged that the tableware and linens and cutlery and crockery are all showing signs of heavy wear and tear and should be replaced as soon as possible. see recommendation . New smaller menu card -holders have been purchased for each of the dining tables, but have not yet been brought into use. However, this will improve the way in which information about meals is shared with residents. See recommendation Mary Chapman Court DS0000044397.V345050.R01.S.doc Version 5.2 Page 15 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): Standards 16,18 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence, including a visit to the service. People who use the service are aware of what do d if they wish to raise concerns or issues about the service. Staff receive training which helps them to recognise and respond to allegations of abuse. EVIDENCE: One complaint has been raised with the service and the CSCI in the last year. The complaint issues have been investigated and a response passed to the operations manager for approval prior to sending to the complainant. The manager will also be contacting the complainant directly to discuss the outcomes and action. A complaint file is maintained and all concerns and comments are logged and any agreed action is also recorded. The manager confirmed that they planned to re-establish the residents/relatives meetings the last one having been held in January 2007, as it is felt they do provide an open forum for expressing views and comments about the service. Once resident said that this would be helpful ‘as face to face discussions about things tends to iron out niggles’ See recommendation As stated in Choice of Home section (standard one) the home does not have an updated Service Users Guide or Statement of Purpose. These documents explain how residents and relatives can complain and this information should be readily available to everyone who uses the service. Four out of fifteen people said through the comment cards that they were unsure how to make a Mary Chapman Court DS0000044397.V345050.R01.S.doc Version 5.2 Page 16 formal complaint should they need to do so. However the majority of residents and relatives were clear about who they would contact should they have any concerns or were unhappy with any aspect of their care. See recommendation. The manager confirmed that the staff group have received training in the protection of vulnerable people and they are also aware of the company whistle blowing procedures which are contained in the policies and procedures and are also contained in the staff handbook Mary Chapman Court DS0000044397.V345050.R01.S.doc Version 5.2 Page 17 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): Standards 19, 20 26 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence, including a visit to the service. The premises are safe and reasonably well maintained and are suited to residents needs. EVIDENCE: A short tour of the premises was undertaken and the environment was found to be clean tidy and well maintained. Safety aspects for the grounds and premise are being addressed, and there are now entry and exit keypads on the external doors. The reception desk is manned from 9am until 3pm each day, which has improved the monitoring of people in and out of the home and also helped to promote improved communication and contact with visitors. On the day of the inspection a problem with the hot water system had occurred but was safely remedied before the end of the day. The manager advised that there are a number of plans agreed for the premises in general including a programme of redecoration and refurbishment for some of the Mary Chapman Court DS0000044397.V345050.R01.S.doc Version 5.2 Page 18 rooms. Carpets in five of the residents rooms are to be replaced in the immediate future and one of the double rooms on the first floor has been refurbished to a good standard and will be used as an activities /meeting room. The external paintwork is to be repainted and repairs and cleaning to the guttering is also being carried out. The grounds and gardens are not at their best due to overgrown bushes and weeds especially to the rear of the premises. The paths are being cleared of moss and grasses and arrangements being made to improve the maintenance plan for the grounds, so that residents will feel safe and confident about using these areas independently. See recommendation. During the tour of the premises it was agreed that the manager will review some of the notices and information displayed to ensure that the information is relevant up to date and appropriately sited. It was also observed that some of the tableware, linens and cutlery in use are showing signs of wear and should be replaced. See recommendation The manager acknowledged that the staff will be asked to pay more attention to the way the dining rooms are laid out and meals are presented to ensure good standards are maintained. There is also a move to change from plastic cups and beakers to sturdy glass tumblers. The staff group have received training and guidance on safe practices and management of infection. The laundry facilities are sited on the first floor, but were not inspected on this occasion. However it was noted that the laundry services appear to be appropriate and well managed. Mary Chapman Court DS0000044397.V345050.R01.S.doc Version 5.2 Page 19 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): Standards 27,28,29,30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using a range of evidence, including a visit to the service. The staff group have good knowledge of the resident’s needs but lack formal training to promote and improve consistent care standards. Robust recruitment and selection processes help to protect residents. EVIDENCE: Residents and relatives stated that they are generally satisfied with the service provision. However, four of the comment cards returned from relatives did not think there are enough care and domestic staff on duty at times especially at week ends, others said the service is not always consistent and small care items get missed or forgotten. Residents seen on the day said that they were happy with the care support they receive from staff and one said there have been staff shortages recently but this has not affected her care in any way. The manager acknowledged that in the last few months there have been a number of staff changes and there are still two vacant care staff posts to be filled and they are trying to recruit suitable carers. Other staff will help to fill in the gaps in the duty rota when sudden absences occur, and the manager can fill vacancies and absences with agency staff when necessary. There is evidence to support the efforts made by the manager to stabilise the staff group and establish and maintain a Mary Chapman Court DS0000044397.V345050.R01.S.doc Version 5.2 Page 20 consistent service. In the last three months the manager has introduced accountability files in each residents rooms so that care input can be monitored and adjusted as needed but is also using the form to measure competency and delivery of the care service by staff. During the discussions the manager agreed there is still work to be done to identify where weaknesses and strengths in professional practice may be and to create personal learning and training packages for staff. A review of the dependency and staffing levels for the home should be carried out to ensure residents assessed needs are being met by adequate numbers of staff. See requirement. Residents seen on the day said that the staff ‘are very good and helpful ’ and ‘always do their best to make sure we are looked after’. Residents also gave good examples of personal help and support by individual members of staff and the management. One resident and one relative said in their comments that they thought the day to day care had improved since the managers appointment in March this year. None of the staff have the NVQ in care qualification, but funding is now in place for formal training to be offered to the staff. The manager is currently undertaking NVQ 4 and two of the senior staff are about to commence their NVQ 3 training. NVQ 2 registration for the care staff group will take place on 26th July 2007 See requirement. Four staff files were seen on the day of the inspection and are well maintained there is evidence of good recruitment and selection procedures, including identity and criminal records bureau checks. Information relating to staff CRB checks should be organised in such a way that the information can easily be accessed for inspection purposes. See recommendation. Mary Chapman Court DS0000044397.V345050.R01.S.doc Version 5.2 Page 21 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): Standards 31,32,33 35,36,38 People who use the service experience adequate quality outcomes in this area. This judgement has been made using a range of evidence, including a visit to the service. The manager is undertaking and discharging her duties and responsibilities well. The financial interests of the residents are safeguarded by good practices and procedures. Formal staff supervision procedures are in place to promote good practice. The health and safety of residents is protected by good procedures. EVIDENCE: The manager Kim Holden has been in post since March 2007 and transferred from one of the company’s other services in the north of the county. Prior to this appointment Kim was a deputy manager in a larger resource with a good reputation. From the discussions on the day of the inspection, the manager demonstrated a caring and committed approach to her work. It is Mary Chapman Court DS0000044397.V345050.R01.S.doc Version 5.2 Page 22 acknowledged that there is much to be done to bring the service to an excellent level. The manager has prioritised much of this work concentrating on monitoring resident need and establishing and upgrading the care planning processes and working on promoting staff stability consistency of the service and implementing accredited training. The manager is to be commended on the positive outcomes achieved in the last three months. There is a small managerial structure in place in that the manager has a senior carer designated as a deputy and an administrator to assist with the administration and reception work. Because of current staff absences due to both leave and sickness the manager and deputy manager are having to undertake some of the direct care tasks, which are impacting on the managerial responsibilities and causing delays in management tasks being addressed and completed. The manager is looking at ways in which members of staff who have demonstrated an interest and insight in a more managerial role will be asked to take on added responsibility in the short term. See recommendation. The manager has yet to submit her application to register with the Commission for Social Care Inspection. See requirement. The last quality assurance survey for the home was carried out in January 2007, however the manager plans to send out the quality assurance surveys to all who use the service including other health care professionals. Relatives and residents meetings will also be re-established as a way of seeking people’s views on the service. See requirement. Staff supervision and appraisal procedures are in place and the manager has begun the process. Progress has been made in this respect and two of the staff seen on the day confirmed that they have received one to one supervision with the manager. See recommendation The management do not have a formal interest in resident’s financial affairs however they do hold and administer small amounts of personal allowance on behalf of residents. A separate record and cash wallet for each person is maintained. Three of these were examined on the day and were well maintained and up to date. Two signatures are required for any expenditure or debit or credit transaction, and receipts are obtained to verify purchases. This home maintains separate accounts and records for each person and do not use business accounts or group accounts to manage resident’s funds or personal allowances. Building and equipment and safety records are in place and well maintained. A maintenance file is kept in date order. Aids and adaptations have been serviced and safety checks carried out on the equipment. Gas and boiler records and services have also been carried out and the records in place. Mary Chapman Court DS0000044397.V345050.R01.S.doc Version 5.2 Page 23 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 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x x x x x 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 x 3 2 x 3 Mary Chapman Court DS0000044397.V345050.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes. 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 OP1 Regulation 4,5,6 Requirement The registered providers are required to update and reissue the Service Users Guide and Statement of Purpose for the service. The registered providers are required to review the staffing levels and residents dependency levels to ensure adequate numbers of staff are on duty to meet assessed needs. The registered providers are required to arrange suitable and appropriate activities and social stimulation for and in consultation with residents The registered providers are required to implement the formal training programme to achieve NVQ qualification for all staff. The registered providers should submit an application to the Commission to register the manager of the home. The registered providers are required to review the quality of care through the homes quality assurance survey processes by seeking the views of those who DS0000044397.V345050.R01.S.doc Timescale for action 31/08/07 2 OP27 18 31/08/07 3 OP12 16 (m)(n) 31/08/07 4 OP28 18c(i) 31/08/07 5 OP31 8,9,10 31/08/07 6 OP33 24 30/09/07 Mary Chapman Court Version 5.2 Page 25 use the service including other health care professionals. 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 OP15 Good Practice Recommendations It is recommended that information about the daily menu and meal options be provided in an easy to read and more accessible format, and the menu cardholders acquired for this purpose be brought into use. It is recommended that a review of all the dining equipment and facilities are reviewed and replaced where there are signs of wear and where necessary including tableware, cutlery, linens and glassware and crockery It is recommended that information about how to make a complaint is made available to residents and relatives as part of the Services users guide and Statement of Purpose. It is recommended that the ongoing improvements to the grounds and gardens are completed so that residents have safe access to the external areas of the home. It is recommended that the dining equipment and facilities are reviewed and replaced or refurbished where there are serious signs of wear and tear. It is recommended that details relating to the CRB disclosures for staff be maintained in a system which can be easily accessed for inspection purposes. It is recommended that the formal supervision and appraisal processes to monitor staff training development and practice are implemented. 2 OP15 3 OP16 4 5 6 7 OP19 OP19 OP29 OP36 Mary Chapman Court DS0000044397.V345050.R01.S.doc Version 5.2 Page 26 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 Mary Chapman Court DS0000044397.V345050.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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