Inspection on 12/06/07 for Mary`s Home

This inspection was carried out on 12th 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`s Home 12/08/08

Mary`s Home 03/05/06

Mary`s Home 09/12/05

Mary`s Home 28/04/05

Mary`s Home 29/10/04

Mary`s Home 27/04/04

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

CARE HOMES FOR OLDER PEOPLE Mary`s Home 88 Warham Road South Croydon Surrey CR2 6LB Lead Inspector Lee Willis Key Unannounced Inspection 12th June 2007 11:30 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 Mary`s Home DS0000025811.V342084.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`s Home DS0000025811.V342084.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mary`s Home Address 88 Warham Road South Croydon Surrey CR2 6LB 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) 020 8688 2072 020 8667 9242 Dr Edward N Osei Appah Mrs Helen Appah Mrs Regina Anima North Care Home 29 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (29) Mary`s Home DS0000025811.V342084.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Six (6) places for service users under the age of 65 years can be accommodated 3rd May 2006 Date of last inspection Brief Description of the Service: Mary’s Home is a privately owned residential care home that provides accommodation and personal support for up to twenty-nine generally older adults with a past or present experience of mental ill health. The homes registered manager, Regina North, has been in operational day-to-day control of the service for over four years. Set back from a busy thoroughfare in South Croydon the home is within fifteen minutes walk of the centre of town and is relatively near a wide variety of local shops, cafes, pubs, and banks. The home does not have its own transport, but it is situated on a main line bus route and is within ten minutes walk of a local train station, with good links to central London, and the surrounding areas. Built over three storeys this extended detached property comprises of twenty-three single occupancy bedrooms, of which sixteen have en-suite facilities; three doubles; a separate dinning room; large main lounge with a designated smoking room attached; kitchen; a laundry and sluice room; two offices; staff room; and passenger lift. The garden at the rear of the property has a large lawn; some well established trees and plants, and a patio area. The provider ensures information about the facilities and services on offer are made available to prospective service users and their representatives through the homes Statement of purpose and Service users guide. The homes scale of charges currently ranges from £400 to £550 per week. Mary`s Home DS0000025811.V342084.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. From all the available evidence gathered during the inspection process the Commission for Social Care Inspection (CSCI) has judged the service as having significantly more strengths than areas of weakness. There are no significant areas for improvement relating to the health and safety of people using the service or issues of poor management. However, although most Key standards are generally met, appropriate action still needs to be taken to improve areas of particular weakness identified in this report. The Commission is confident the providers will respond well to all the issues raised. This unannounced site visit was carried out on a Tuesday afternoon between 11.30am and 4.30pm. During the course of this five-hour inspection six people who live at the home were spoken with at length, along with several of their guests, which included the relatives of two service users, a Community Psychiatric Nurse (CPN), and a Dental hygienist. The homes registered manager, three support workers, the cook, and a student nurse on placement, were also met during this site visit. The remainder of the time was spent examining the homes records and touring the premises. The Commission received four ‘have your say’ comment cards about the home. These were all completed by people who live at the home, although most were supported by their relatives or keyworker in this task. What the service does well: What has improved since the last inspection? Mary`s Home DS0000025811.V342084.R01.S.doc Version 5.2 Page 6 The home has improved its record keeping in relation to handling Controlled drugs and now full complies with the relevant legislation to ensure the health and welfare of service users is protected. All the homes staff have recently attended safeguarding adults training to ensure they have the necessary knowledge and skills to recognise, prevent and appropriately deal with actual or suspected abuse within the home. Service users and their representatives views about the standard of care provided at the home are now published ensuring their opinions underpin the homes development. What they could do better: All the positive comments made above notwithstanding there are some areas of weakness that need improving: The homes financial arrangements for charging service users for the facilities and services provided are not particularly transparent and will need to improved to enable people to make informed decisions about whether or not they are getting value for money. The staff team need to be reminded about their duty of care not to allow other health care professionals to carry out intimate medical checks in communal areas in full view of other service users and their guests. This practice is clearly undignified and contravenes service users right to see visiting health care professionals in the private. More suitable floor covering needs to be laid in one bedroom to minimise the risk of offensive odours lingering in this area. Arrangements for checking the suitability of students working on placement at the home need to tightened up and a working with students policy established to ensure service users are not placed at risk of being harmed by people who are not ‘fit’ to work with vulnerable adults. The homes manager clearly recognises the importance of staff training, and therefore it was disappointing to note that Regina North has still not obtained a National Vocation Qualification Level 4 in management and care. The manager must obtain this award if she is to be considered suitably qualified to run a residential care home. Mary`s Home DS0000025811.V342084.R01.S.doc Version 5.2 Page 7 As part of having an effective quality assurance system the providers must ensure unannounced monthly inspections of the home by people who do not work there are reintroduced and the results of their findings published for all to view. 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`s Home DS0000025811.V342084.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`s Home DS0000025811.V342084.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 Quality in this outcome area is good. This judgement has been made using all the available evidence both during and before the inspection visit to this service. People who use this service generally have good information about the home that enables them to make an informed decision about whether the service is right for them. The homes current arrangements for charging service users for the facilities and services provided are not particularly transparent and will need to improved to enable people to make informed decisions about whether or not they are getting value for money. EVIDENCE: A copy of the homes most up to date Statement of Purpose and Guide was produced on request. The manager told us that the document was last reviewed in January 2007 and had been up dated accordingly to reflect any Mary`s Home DS0000025811.V342084.R01.S.doc Version 5.2 Page 10 changes in provision. The document clearly sets out the objectives and philosophy of the service and what the people who use the service can expect in terms of the quality of the accommodation, qualifications of staff, and how to make a complaint if they are dissatisfied with any aspect of their care. However, the date recorded on the guide revealed the document had not been amended since February 2005. Nor did the document contain any details in respect of the fees payable for services and the arrangements in place for charging for additional services not covered by the basic cost of each resident’s placement. The homes Statement and guide also need to be amended in light of the changes made to the homes conditions of registration to accurately reflect the age range of the people for whom the service is intended (I.e. for people with a past or present experience of mental ill health who are over 50 years of age). The manager told us that the homes Statement did not contain the views of any of the people currently living at Mary’s home; despite recently carry out a resident’s satisfaction survey as part of the homes new quality monitoring systems. Two service users spoken with told us they had been given a copy of the homes Guide before they had moved, which they kept in their bedroom. The relatives of a service user met during this site visit told us they had been copies of the homes Guide before their loved one had moved in and had found the information it contain very useful. The manager told us she had not received any new referrals since the homes last inspection, although one individual had recently moved out. The manager was very clear about the range of needs the home intended to meet and is commended for supporting this individual, whose primary care needs on admission had significantly altered, to move into more suitable accommodation where staff had the necessary training to meet their new needs. The manager confirmed that is was customary for all prospective service users to be asked about their religious beliefs and clearly understood the importance of ascertaining this type of information prior to admission. Mary`s Home DS0000025811.V342084.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 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. In the main care plans reflect what is important to the individual, there capabilities and what support they need to achieve their personal aspirations. Sufficiently robust arrangements are in place to ensure the people who live at the home receive personal support in the way they prefer and require, and that their unique physical and emotional health care needs are always recognised and met. The homes policies and procedures for handling medication are sufficiently robust to minimise the risk of service users being harmed. People who live at the home are treated with respect and their right to privacy is upheld. Mary`s Home DS0000025811.V342084.R01.S.doc Version 5.2 Page 12 EVIDENCE: The individual care plans for the three people selected for case tracking were examined in depth. The documents contained information about each person needs, strengths, and the actual support they each required to meet their unique personal, social and health care needs. The manager was able to describe how they use and help develop care plans, and accurately described the plans for the three service users whose care was being case tracked. This knowledge means that service users can be confident that they will get support from people who understand their care needs. The manager told us that if they felt service users needed to see a doctor or any other health care professionals staff would always notify the relevant parties without delay. During the course of the inspection a Community Psychiatric Nurse (CPN) and a dental hygienist arrived to carry out prearranged health care check ups. The CPN told us the staff always contacted her without delay if they had any concerns about her ‘clients’ mental health. Two service users met said their CPN and dental hygienist visit the home on a regular basis. The appointments service users attend with various health care professionals, including GP’s, CPN’s, District Nurses, dentists, opticians ect… are recorded in the house diary. For reasons of confidentiality the outcome of these appointments cannot be recorded in the homes diary and it is therefore recommended more detailed information about how each service users health care needs are being met are included in their care plan. Staff maintain records of all the accidents and significant incidents involving service users. The accident book revealed that two falls had occurred in the home since February 2007, which resulted in one service user being admitted to casualty for stitches. A senior member of staff spoken with about the homes medication handling arrangements was acutely aware of the need to vigilant when receiving medication into the home. No errors were noted on medication administration sheets sampled at random and these records matched the stocks currently being held by the home on service users behalves. During a tour of the premises a visiting dental hygienist was observed providing oral treatment to service users in the communal lounge in front of other service users, visiting relatives, and several members of staff. Having witnessed this poor practice the manager told the visiting hygienist that providing medical treatment in communal areas was unacceptable and must cease immediately. The hygienist was told to see service users in the privacy of their bedrooms. The staff on duty in the lounge who were all witnesses to this undignified practice should have taken swifter action to prevent it. Mary`s Home DS0000025811.V342084.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A good range of activities within the home and community mean the service users have various opportunities to participate in stimulating and fulfilling activities Specific dietary needs and cultural tastes are well catered for, providing daily variation, choice, and interest for the people who use the service, although more could be done to ensure service users participate in the process of planning the menus. EVIDENCE: Four service users spoken with told us they are able to do as they please each day. One service user spoken at length told us they looked forward to having their weekly massage and music sessions held in the main lounge. On arrival it was positively noted that a member of staff was observed dancing with a service user to Caribbean style music in the main lounge. Several other service users met said they also enjoyed the weekly music and movement classes. During a tour of the premises a large collection of books and board games was Mary`s Home DS0000025811.V342084.R01.S.doc Version 5.2 Page 14 noted stored on opening shelving in the lounge. The manager told us a wide selection of books and games and continually replaced by a local library service that visits the home every quarter. Visiting relatives told us that although their loved one often declined to participate in any community based activities they were nevertheless opportunities for others to go on day trips to the coast and the theatre. One service user met said they had really enjoyed going to the theatre. Minutes of service users meetings revealed that people who live at Mary’s home are about the type of social activities they would like to participate in and more specifically where people would like to go on day trips. The manager said residents are consulted about what recreational activities they would like to pursue, which is recorded in their care plans. Nonetheless, the Commission feels the manager should make more of a concerted effort to gather find out about what’s going on in the local community and make this information about local activities more widely available to service users. Service users spiritual needs are recorded in their care plans and the manager told us the three practicing Christians who currently live at the home regularly attend services at a local church. Three relatives met during the visit told us they were not aware of any restrictions on visiting times and were able to meet their loved in the privacy of their bedrooms if they wished. The homes visitors book is available in the entrance hall and staff ensure all visitors to the home sign it on their arrival. The meals on offer each day are conspicuously displayed on a notice board in the dinning room. The original lunchtime choices of beef casserole and steamed fish were not available on the day and had been replaced with two alternative dishes. One service user told us over lunch that on the whole the published menus usually matched the meals provided and that they were quite happy with the choices on the new lunchtime menu. Four service user met told us that they were all satisfied with the quantity and quality of the meals on offer. The size of the portions served over lunch appeared to be sufficiently large to satisfy the appetites of the service users. A number of service users met said they always had the option of choosing Afro-Caribbean style cuisine, such as curried goat, salt fish, and plantain. These culturally specific style meals could be identified from the published. The manager told us that one service user who originally came from the Caribbean was actively encouraged and supported by staff to do their own food shopping and prepare Caribbean style dishes. Two service users met, who happen to be vegetarians, told us there was always meat free-options available at mealtimes. The cook told us that she always prepare a sugar free dessert to meet the dietary needs of service users with diabetes. Mary`s Home DS0000025811.V342084.R01.S.doc Version 5.2 Page 15 Information about service uses specific dietary needs is included in their care plans. However, it is recommended that more detailed information about peoples food preferences and dislikes are contained in these documents and more proactive steps are taken by staff to actively encourage service users to help plan the menus, e.g. Consider holding weekly service users meetings to plan the forthcoming weeks menu. Staff maintain an up to date record of all the food consumed by service users which revealed people who live at Mary’s Home are offered a wide variety of nutritionally well-balanced meals. Mary`s Home DS0000025811.V342084.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): No’s 16 & 18 Quality in this outcome area is good. This judgement has been made using all the available evidence both during and before the inspection visit to this service. The homes arrangements for dealing with complaints and allegations of abuse are sufficiently robust and understood by staff to ensure people who use the service feel listened to and safe. EVIDENCE: A copy of the homes complaints procedure is included in the service user guide and specifies who deals with them and how long a complainant can realistically expect to wait for a response (i.e. within 28 days). The manager confirmed that no complaints or allegations of abuse had been made about the homes operation in the past twelve months. One service user and their visiting relatives met during this site visit all told us that if the need arose for them to complain about any aspect of the homes operation they felt confident their concerns would be taken seriously and dealt with. Mary`s Home DS0000025811.V342084.R01.S.doc Version 5.2 Page 17 The manager demonstrated a good understanding of the action she would need to take if an allegation of abuse was made within the home. Documentary evidence was made available on request to show that sufficient of the homes current staff team had already attended the local authorities vulnerable adult protection course or were booked to receive this training by the end of July 2007. Mary`s Home DS0000025811.V342084.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall décor, and condition of the fixtures and fittings in the home ensures the service users live in a relatively homely and comfortable environment. EVIDENCE: There have been no significant changes made to the interior design or décor of the home since it was last inspected. Several service users who were met whilst relaxing in then large garden said the relatively new lay out of the garden was the thing they liked best about the home. One service user said they liked to sit at the far end of the garden and enjoy a cigarette in private. The home has a designated smoking area attached to the rear of the property, which in line with the Governments new legislation on smoking, is used solely Mary`s Home DS0000025811.V342084.R01.S.doc Version 5.2 Page 19 for this purpose. The manager should consider fitting an extractor fan in this enclosed space to reduce the built up of smoke in this relatively small area. One service user spoken with at length said they were very pleased with their new bedroom and liked the colour it was painted. Another service user told us they had enough space in their bedroom to store all their clothes. During a tour of a double bedroom on the ground floor it was noted a cupboard door on a wash hand basin sink was damaged. Furthermore, it was noted that quite a strong odour lingered in this room and the manager agreed the carpet would need to be replaced with more suitable floor covering. The manager told us that all the homes shower facilities had been fitted with suitable thermostatic mixer valves that prevented water temperatures exceeding 43 degrees Celsius, in line with health and safety regulations. They temperature of hot water emanating from the first floor bathroom in the original wing of the home was found to be a safe 43 degrees Celsius when tested at 13.50. The call bell cord in the room was not long enough to reach the floor and therefore could not be assessed by a service user who had fallen over. The cord will need to be extended as a matter of urgency. During a tour of the premises it noted to be clean throughout. The homes washing machine is capable of cleaning laundry at appropriate temperatures and has a sluice programme for dealing with foul laundry. Sufficient supplies of latex gloves and plastic aprons were found in this area for staff to wear as and when required. The manager demonstrated a good understanding of the homes arrangements for disposing of this type of waste. Mary`s Home DS0000025811.V342084.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): No’s 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using all the available evidence both during and before the inspection visit to this service. Sufficient numbers of suitably competent and experienced staff are employed on a daily basis to ensure the service users needs are met. Procedures for recruiting permanent members of staff are sufficiently robust to protect the service users from harm, although arrangements for checking the suitability of students on placement will need to be improved as a matter of urgency. EVIDENCE: On arrival three support workers and the registered manager were all on duty. The manager confirmed that at least three staff are always on duty during the day. All the staff on duty at the time were observed interacting with the service users in a very patient and professional manner throughout the course of this inspection. The manager told us that out of a total of 16 support workers currently employed to work at Mary’s Home, 6 had achieved an NVQ level 2 or above in care and a further 3 were on course to have completed their NVQ training by the end of September 2007. Mary`s Home DS0000025811.V342084.R01.S.doc Version 5.2 Page 21 The home continues to experience relatively low rates of staff turnover and consequently the manager has not needed to recruit any new members of staff in 2007. The manager told us that a student nurse is currently on placement at the home. The student’s personal file was examined in depth and found to contain two written references and an up to date Criminal Records Bureau. However, the individuals CRB revealed that they had not been checked against the protection of vulnerable adults register, contrary to recruitment legislation. The home will need to improve its arrangements for carrying out recruitment checks, and establishment a working with student’s policy. This policy must cover their recruitment, induction training, roles and responsibilities, and supervision. The manager told us the new student had received a thorough induction before starting their placement at the home. Staff spoken with were very clear about their roles as support workers and knew what was expected of them. Documentary evidence was produced on request in the way of certificates of attendance that showed sufficient numbers of the current staff team had received mandatory training in fire safety, first aid, food hygiene, and health and safety. Mary`s Home DS0000025811.V342084.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): No’s 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using all the available evidence both during and before the inspection visit to this service. The homes manager is not suitably qualified to run a residential care home and will need to complete the relevant NVQ 4 training course in order to obtain the necessary management skills. The homes new quality monitoring system ensures service users and their representative’s views about the standard of care provided underpins the homes development, although unannounced monthly visits by a representative of the providers still needs to be established as an additional means of assuring quality. The homes health and safety arrangements are sufficiently robust to safeguard the health and welfare of service users, their guests, and staff. Mary`s Home DS0000025811.V342084.R01.S.doc Version 5.2 Page 23 EVIDENCE: The homes manager is still not suitably qualified to run a care home. The manager told us she has enrolled on a new NVQ course and plans to have completed the training by November 2007. The timescale for the manager to have completed her NVQ level 4 training in both management and care does not expire to the end of 2007 and therefore this outstanding requirement will merely be repeated in this report. Since the homes last inspection the manager has attended training in supporting people with dementia, equality and diversity, and health and safety. The manager was able to produce written evidence to show that she is in the process of securing the services of an independent consultancy firm to carry out monthly-unannounced inspections of the home. The manager told us that this was still a work in progress and consequently the manager was unable to produce any Regulation 26 reports for the home since Christmas 2006. However, the manager was able to produce the results of surveys that were used to ascertain the views of service users, their relatives and professionals representatives about the homes operation. The balances recorded on three service users financial sheets inspected at random matched the amount held by the home on their behalves. Staff record all the financial transactions between themselves and service users and receipts are always obtained. Service users money being looked after by the home was securely stored away in a lockable space. Up to date Certificates of worthiness were in place to show that suitably qualified engineers had checked the homes fire extinguishers, portable electrical appliances, passenger lift, and water heating in the past twelve months. The homes fire records revealed that the fire alarm system continues to be tested on a weekly basis and fire drills involving all the service users are still undertaken at least once a quarter, in line with LFEPA guidance. Mary`s Home DS0000025811.V342084.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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 2 X 2 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Mary`s Home DS0000025811.V342084.R01.S.doc Version 5.2 Page 25 Yes 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 OP1 Regulation 5(1)(bb) & (bc) Requirement The Service users Guide must contain details of the fees payable in respect of facilities and services provided and the arrangements that are in place for charging for additional services not covered by the basic cost of each service users placement. Staff must be reminded of their duty of care to ensure service users receive medical treatment from visiting health care professionals in private. Call bell cords must reach the floor to ensure service users can access this alarms should they fall. Damaged door attached to the under the sink cupboard in a double bedroom nearest the front door must be repaired. Timescale for action 01/07/07 2. OP10 12(4)(a) & 18(1) 01/07/07 3. OP22 13(4) & 23(2)(c) 01/07/07 4. OP24 23(2)(c) 01/07/07 Mary`s Home DS0000025811.V342084.R01.S.doc Version 5.2 Page 26 5. OP24 16(2)(k) (c) More suitable floor covering must 01/08/07 be laid in the double bedroom nearest the front door to eliminate the offensive odour in this area. All students on placement at the home must be checked against the Protection of vulnerable adults register. The registered manager must have achieved an NVQ Level 4 in Management and Care by the end of the year. Documentary evidence of this qualification must be made available on request. The manager must establish a working with student’s policy that covers their recruitment, induction training, roles and responsibilities and supervision. The responsible individual who is assigned the task of carrying out unannounced monthly inspections of the home on behalf of the registered provider must interview service users and staff; inspect the premises; examine records of events and complaints; and prepare a written report for the Commission each month. Previous timescales for action of 1st June 2006 and 1st May 2007 both not met. 01/07/07 6. OP29 19(1), Sch 2.2 7. OP31 9(2)(b)(i) 01/01/08 8. OP33 18(1) (2) 01/08/07 9. OP33 26(2), (3), (4) & (5) 01/09/07 Mary`s Home DS0000025811.V342084.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP1 Good Practice Recommendations The Service users Guide should include stakeholder’s views about the care provided at the home. More detailed information about the outcome of service users appointments with health care professionals, including GP’s, CPN’s, District Nurses, dentists, opticians, Chiropodists, should be recorded in care plans. Information about social activities and events happening in the local area should be more conspicuously displayed in the home so service users have greater access to it. More detailed information about service users food preferences should be contained in their care plans. Staff should also be more proactive when it comes to enabling service users to plan the weekly menu. An extractor fan should be fitted in the designated smoking room to reduce the built of smoke in this relatively small space. 100 of the homes staff team should have either achieved an NVQ level 2 or above in care or be working towards this aim by an agreed date. OP8 3. OP12 4. OP15 5. OP19 6. OP28 Mary`s Home DS0000025811.V342084.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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`s Home DS0000025811.V342084.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. 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