Inspection on 10/08/06 for Mary Street

This inspection was carried out on 10th August 2006.

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 Street 16/01/06

Mary Street 22/08/05

Mary Street 10/02/05

Mary Street 05/08/04

Mary Street 21/01/04

Mary Street 19/08/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Mary Street 179 Mary Street Balsall Heath Birmingham West Midlands B12 9RN Lead Inspector Susan Scully Key Unannounced Inspection 10th August 2006 10:00 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 Street DS0000017013.V308280.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 Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mary Street Address 179 Mary Street Balsall Heath Birmingham West Midlands B12 9RN 0121 446 5719 F/P 0121 446 5719 valp@fch.org.uk 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) FCH Housing & Care Mrs Valerie Paragon Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Mary Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Up to 21 service users requiring care by reason of old age (over 65). This number may include the one existing service user as at 2003, who requires care by reason of physical disability. That the home can accommodate one named service user over the age of 65 for reasons of Mental Disorder. 16th January 2006 Date of last inspection Brief Description of the Service: FCH Housing and Care own and manage 179 Mary St, which is registered to provide care and support to 20 older people and one younger adult with a physical disability. It currently offers this service to people from the AfricanCaribbean community. The home is situated in a residential area and is close to local shops, pubs, medical centre and places of worship. It is well served by public transport. Facilities briefly include 21 individual flats, each with its own lounge, bedroom, bathroom and kitchen. Each flat has a buzzer facility to summon staff for assistance. Service users have their own lockable front door. Service users can decorate and furnish their flats to individual taste. FCH Housing and Care are responsible for the maintenance and repair of the flats and the rest of the building, which consists of a communal lounge, dining room, office, staff rooms and laundry. FCH Housing and Care also maintain the grounds. Mary Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit took place by two inspectors to this service over a oneday period. Information had been collected using a pre-questionnaire, regulatory activities and information received before the field work to from part of this report. During the visit, records were sampled pertaining to service users care plans, healthcare records, daily activities, and polices and Procedures. Health and safety procedure were also sampled. Including servicing of any manual handling equipment, such as aids and adaptations that had been made to the environment to enable the service to meet individual needs. During the last fieldwork visit, 2 requirements were made and although these have not been met, progress has been made and it is anticipated these will be met at the next before the next visit. The fees payable for accommodation are £368 per week. Aids and adaptations are provided based on the assessed needs of service users. All service users live in individual flats with their own front door, provisions for cooking and all have en suite facilities. What the service does well: What has improved since the last inspection? The manager and staff have continued to provide a service that is user orientated. The views of service users are listened to and action is taken to respond promptly to concerns or complaints. Mary Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mary Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 7 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 Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 8 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, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. No service user moves into the home without having received a full assessment before admission by a competent person. Intermediate care is not provided. EVIDENCE: A service user had recently been admitted to the home. The placing authority and the manager had completed an assessment. The service user had visited the home previously and received information to enable them to make the decision if this service could meet their identified needs. Once the assessment has been completed, the information collated is then transferred into a care plan in full consultation with the service user. After 28 days a review takes place and if the needs of the service user can be met and the service user agrees a permanent placement if offered. Mary Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 9 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 adequate. This judgement has been made using available evidence including a visit to this service. Care plans sampled did not demonstrate reviews take place on a regular basis. This may potentially place service user at risk. Service users attend regular visits to other health related services to ensure their health and wellbeing is maintained. The policy and procedure for the administration and recording of medication is not robust to ensure service users receive the correct amount and dosage of medication. Service users are treated with respect and their privacy and dignity is maintained. EVIDENCE: Care plans in general provide information to enable staff to meet the needs of the service users. Information contained in care plans show how the needs of service users will be met by giving specific instruction to staff. Daily records do Mary Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 10 not always cross reference to the care plans. Care plans that were sampled during the visit required updating. For example in one care plan the information recorded stated the service users used a Zimmer frame. The inspectors observed the service user using a wheel chair. This was not recorded in the care plan. When speaking with the manager the inspectors were informed the service user is encouraged when possible to use the Zimmer frame however, on some days this was not possible as the service user became tired. This information must be reflected in the care plan to ensure all staff are aware that the use of the Zimmer frame depends on the service user capabilities on different days. In another care plan it stated the service user had recently lost weight due to illness, staff were to monitor the weight loss on a weekly basis. The records showed this was being completed monthly. There was no nutritional screening in place or risk assessment to ensure the service user had regular meals and fluids. In the care plan, it clearly stated the service user was at risk from malnutrition. In one care plan it had been identified the service user needed help with shaving. The care plan did not say if the service user had a wet shave or used an electric razor or the preference of how many times a week he would like the shave. Other information contained in care plans and daily records was more specific, such as how personal care was to be provided when assistance was required with bathing, and how the service user liked to have a lotion put on their skin each morning. Other information stated how the service user needed to be reminded each day to elevate their legs. This information was recorded daily. One-service user spends most of their time in bed due to illness, there was no tissue viability assessment completed to ensure the prevention of pressure sores. The manager said the district nurses visit the service user every day and she would seek their advice. Risk assessments are completed but not always reviewed. For example one service user has bed rails, there was no risk assessment completed. The manager said the district nurses come in every day, however the inspectors noted that there were large gaps between the bed rail and the bed. A risk assessment must be completed immediately and action taken to involve other professionals to assess the suitability of the bed rails. The manager said she would contact the district nurses for an assessment to be completed. Based on service users needs, there was very good information pertaining to doctors visit, chiropody, hospital visit, hairdresser, activities, opticians, and when other health professional are involved in the care of service user. All concerns are recorded and how the service users want their personal care to be delivered. Information was also recorded to show regular visits to hearing aid departments. Omissions in care plans may place service users at risk. Mary Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 11 The manager must ensure there is a balance with what information is recorded. The care plan must be reviewed monthly or before if, a new need is identified. They must also demonstrate what influences the new needs have on existing care needs. Care plans must be evaluated, monitored, reviewed and reevaluated to ensure consistence with the care provided. One service user said “ The staff care for me very well, I have no problems if I ask them to do something then they will, the manager or a member of staff asks me if I am happy, if there anything I need and look after me well’’. “When I was ill I could not have asked for better care, I was so glad when I came home from hospital, the staff would come in and see if I was alright, and waited on me hand and foot’’. “ The staff are really kind and support you when you need it’’. “ They treat you with respect. One service user said “ They always knock on your door even though I leave my door open, they ask want you want for meals, if you want to have a chat, are you ok, and when your not they come in more often to make sure your alright’’. Medication records show regular audits are completed. The manager must ensure copies of prescriptions are maintained in order to ensure the medication received can be crossed referenced to the prescriptions. Two signatures are required for all written entries on MAR Charts (Medication administration records). Records are kept of all medication received, and all medication returned to the pharmacy. The Mar charts do not always reflect medication carried forward if there is a surplus left. The manager must ensure any surplus of medication that is not returned to the pharmacy is recorded as carried forward on Mar charts. Staff who administer medication must have completed training in the safe handling and administration of medication. The 5 staff identified as not having completed training must not administer medication until they have completed the course. Mary Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 12 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. This judgement has been made using available evidence including a visit to this service. The service promotes independence and encourages service user to pursue recreational activities and interests both in the home and the local community. Service users maintain very good links with family and friends and are supported when required. Service users make their own decisions each day with assistance from staff when required. Meals provided meet service user needs, are well presented and cater for religions and cultural preference. EVIDENCE: Records sampled in daily activities and care plans indicated that staff enable service users as much as possible to maintain and develop social, emotional, communication and independent living skills. From sampling service users records, from talking to staff and from observations made during this inspection it is evident that service users are supported to participate in activities in the local community. Service users go Mary Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 13 shopping, to restaurants, cinema, out with their friends and family, walks, and the pub. Inside the home, there are televisions, videos, and music systems in the main communal areas. Service users also have the benefit of going into their flats and having friends and family visit them in private. When speaking with service users one service user said “ I enjoy gardening and I have a patch in the back garden where I grow vegetable. “ A lot of other people do too, I go out when I want to and go where I want to, if I need help then I ask staff’’. Recorded in care, plans are the service user preference in relation to religion and cultural needs; personal relationships close friends and next of kin. The service provides activities in house such as karaoke night and quizzes. Regular meetings take place in order to establish what service users want in the form of activities. Service users spoken with in general felt their rights and choices were respected. Menus were sampled which showed a variety of food and drink available. The inspectors observed the lunchtime meal. Information was available for diabetic, cultural meals, what service user did not eat, what service user wanted and how they wanted their meals presented such as no gravy, no sugar, allergies, and reducing diets. This information was clearly displayed in the kitchen. The information also crossed reference to care plans so there could be no mistakes even if an agency cook was used. Service users used aids to assist with eating their meal, such as knifes and forks with specially adapted handles. Social interaction with staff was in general positive. A record of food and drink provided to each service user is maintained. One service user said “ The meals are very good always nice and hot, you can have what you want and we have meetings to see what the food is like and if we want it changed’’. It was observed that service users are being asked what they wanted. The inspectors raised a concern with the manager. One service user was being assisted with their meal, and the interaction with this service user was very limited. Words like chew and open your mouth is not interaction. The manager said the service user did not talk very well and the staff had to ensure the service user did not retain food in their mouth. While this is appreciated, it is the inspector opinion staff could still hold a conversation even if the service user did not always acknowledge what was being said. Staff could talk about the whether or if it was raining or sunny. Because the service user is not able to communicate verbally does not mean the service user should not receive positive interaction from staff. Mary Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 14 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 poor. This judgement has been made using available evidence including a visit to this service. All complaints and concerns are fully investigated. Service users are not fully protected from harm or abuse. The lack of staff training may inadvertently raises the risk of harm to service user. EVIDENCE: All complaints and concerns are recorded. Once a concern or complaint is received, it is documented and the outcome is documented. There have been 11 concerns raised since the last inspection, these have been pertaining to service users, such as laundry not being taken down to the laundry room, cleaning of flats, one service user about another. All concerns have been successfully resolved to the satisfaction of the service users. The majority of concerns have been raised in service users meetings however these are still recorded as concerns. One service user said, “If I have a complaint then I tell the manager, who will try and see if she can do anything about it, she will come back to me with the answer’’. “ I don’t have any problems, they are good here they ask if you are alright and if you feel a little fed up they will come and have a chat’’. In general, conversation with service users they said they knew who to complain to. The complaints procedure is given to all service users. There was evidence with other documentation in those flat visited. Mary Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 15 The service aims to ensure that service users are safeguarded from abuse, and policies and procedures are in place to this end. The staff spoken to demonstrate an understanding of what constitutes abuse, and that there were adult protection policies and procedures in the home to follow should they ever suspect that abuse was taking place. The homes adult protection policy and procedure complies with the Department of Health Guidance No Secrets, including a whistle blowing procedure. Training in adult protection had not been completed for all staff. There were 12 staff who had not completed training in adult protection according to the training records sampled, this may hinder any investigation or concern raised by service users if staff have not received up to date information. Training records also identified 13 staff require training in manual handling, 5 have received no training and 8 staff require an update as the last recorded training was in 2004 this may un-intentionally place service user at risk. The manager must ensure all staff have completed the relevant training to fully protect service users from harm inadvertent abuse Mary Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 16 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, 22, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a secure well-maintained environment. Communal facilities were required have been adapted to meet service user needs and assist in maintaining their independence. A more robust cleaning schedule needs to be developed to ensure all areas of the home are maintained to a satisfactory level of cleanliness. EVIDENCE: In general, Mary Street is maintained to a satisfactory standard. Repairs are reported. The maintenance records do not always show all repairs are completed. Most entries have been signed to say the action taken and repair completed, but there are entries that have not been signed off. The manager said some Mary Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 17 are an oversight and most repairs are completed within seven days, or longer if parts are needed. Aids and adaptation have been fitted in communal bathrooms and are serviced on a regular basis. These included a bath hoist and raised toilet seats. The home provides grab rails along the corridors. Each individual flat and communal area is fitted with an emergency alarm system to summon help in an emergency. Each service user had been assessed for adaptations that were needed in individual flats. A tour of the building and the invitation to view service user flats, showed in one flat cleaning was at a very poor standard. The service user spent most of the time in bed. Staff must ensure the environment is kept clean when service users do not have the ability to maintain standards of cleanness within their flats. The service user spends most of the time in bed; it is imperative for the service user environment to be clean and comfortable to enhance the quality of life for the service user. The main kitchen presented with areas that require a deep clean. For example extractor fans above the cooker, spillages of grease down the side of the cooker on the walls and floor. Shelves where dried food is stored, sauce bottles that have sauce that has dried around the top. Chopping boards were in need of replacement. All of the above could result in cross infection and place service user at risk from sickness. COSHH items were stored securely with COSHH data sheet available for emergency treatment if required. All food stocks are labelled with a use by date. Temperatures are recorded on a daily basis of fridges freezer and food that is served to prevent contamination. Infection control is maintained in accordance with polices and procedure including a clinical waste contract. Communal areas are clean and fresh. Mary Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 18 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 poor This judgement has been made using available evidence including a visit to this service. Training has not been completed in all mandatory areas to ensure that all staff have the relevant skills and competency to ensure the needs of service users are met. Training records sampled demonstrate significant shortfalls in ensuring service user are in safe hands at all times. Policies and procedure and recruitment are robust and protect service users. Training records do not reflect staff skills and competency. EVIDENCE: Staff observed during the inspection were seen to have in general very positive interactions with service users and service users appeared happy and comfortable in the presence of all of the staff. The required numbers of staff were on duty in line with the rota inspected. Domestic staff are employed in addition to the staff that provide the care to service users. The manager said she seldom uses agency staff and has built up reserve staff she can call on when staff are sick or have taken annual leave. This provides continuity for service users. Depending of the needs of the service users, the manager said she would assess when required. As good practice, she is advised to maintain records of her assessment. Mary Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 19 All shift times incorporate a short period for a handover to take place. The inspector sampled 18 Training records that indicated 12 staff required Adult protection training. 13 staff required manual handling. 5 required medication training, and the majority of staff have not completed NVQ level 2 or above. Training records indicted 11 out of the 18 have not completed training in basic food hygiene. Training records indicated 7 staff had received training in fire safety awareness in 2005, the remainder either had completed training before 2005 or had not received fire safety training. The inspector sampled three staff files. These included a recent photograph, completed application form, two written references, birth certificate, passport, evidence of qualifications and evidence that a criminal records bureau check has been undertaken. All staff complete a declaration that they have no criminal conviction. This is also checked against the Protection of Vulnerable Adults Register (POVA), and the Criminal Records Register (CRB). Mary Street has a structured induction process to identifying training needs and supervision. Staff confirmed regular supervision is completed, and records demonstrate supervision is completed at least six times per year. Based on the evidence from training records the manager must ensure that at all time suitably qualified trained staff are on duty to ensure the safety of service users. Mary Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 20 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, 36, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home in general is well run and managed by an experienced manager who ensures service user needs are met. The manager strives to ensure the home is run in the best interest of service user. Service users are protected by the homes policies and procedure in relation to financial and accounting practice. All staff receive regular supervision and ongoing monitoring in relation to their performance. General practices within the home promote the health safety and welfare of the service users, but members of staff must complete training in relevant areas to fully protect service user health and wellbeing. Mary Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager strives to maintain standards within the home and ensure the home is run in the best interest of the service users. The manager is very experienced and uses her knowledge to ensure service user needs are met. Recording and reviewing of information pertaining to service user care plans and risk assessments in general are maintained, however the one sampled do reflect there is a need to ensure when delegated task are given to staff the manager then completes a random inspection to ensure these have been completed accurately. Service users spoken with gave positive views about this service one in particular wanted the report to state that having been at the home for a number of years how happy they were with care and the support they received from the manager and staff. The inspectors randomly selected records of service users money that had been handed into the home for safekeeping. Money that is held on behalf of service user is audited on a regular basis. All transactions are recorded and receipted. Staff files sampled showed supervision is completed on a regular basis and involves a personal development plan for identifying training needs. Health and Safety records were seen and included Fire Safety, Fire Safety Training and Fire Drills. All staff must complete fire safety training. This must be updated twice a year. All staff must complete training in manual handling, food hygiene, and adult protection to ensure the health and welfare of service user is not compromised by lack of experience. All equipment such as gas the landlord’s safety certificate, and lifting equipment is serviced on a regular basis. All accidents are reported to the relevant professional bodies such as RIDDOR, and the Commission. Accident records are maintained in line with Data Protection. Mary Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 22 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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Mary Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 23 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 2 3 Standard OP7 OP7 OP7 Regulation 15(2)(b) 13(4)(c) 15(2)(b) 13(4)(c) 13(4)(c) Requirement Care plans must be reviewed on a regular basis and reflect the current needs of service users. Risk assessments must be reviewed and monitored. A risk assessment must be completed and an assessment carried out for the suitability of the use of bed rails. A copy of prescription must be maintained to ensure a crossreference can be made with all medication brought in to the home. All hand written entries on medication administration records must have two signatures. All staff who administer medication must complete training in the safe handling and administration of medication. Medication records must demonstrate a robust procedure. All medication held in the home must be accounted for. All staff must complete training in adult protection. Timescale for action 01/10/06 01/10/06 15/09/06 4 OP9 13(2) 01/10/06 5 OP9 13(2) 01/10/06 6 OP9 13(2) 01/10/06 7 OP9 13(2) 13(4)(c) 13(4)(c) 13(6) 18(1)(c,i) 01/10/06 8 OP18 OP38 01/10/06 Mary Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 24 9 OP26 23(2)(d) 10 OP27 OP38 18(1)(a) 13(6) 18(1)(a) 13(6) 11 OP28 OP38 12 OP28 18(1)(a) A robust cleaning procedure must be introduced to ensure all areas of the home are maintained to a satisfactory standard. Training records must demonstrate qualified and experience staff are on duty at all times. All staff must complete training in food hygiene, manual handling, fire safety, first aid, and have a personal development plan. The Registered Person should demonstrate that 50 trained members of care staff NVQ level 2 is achieved. Previous time scale 31/03/06. Outstanding from the last inspection. The Registered person should ensure that the staff training programme meets with the Skills for Care targets specifically the time scales. Previous time scale 01/05/06. Outstanding from the last inspection. 01/10/06 01/10/06 01/10/06 01/10/06 13 OP30 18(1)(a) 01/10/06 Mary Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 25 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 OP25 Good Practice Recommendations A copy of the most recent Legionella certificate should be forwarded to the Commission. Confirmation that radiators are covered or have guaranteed low temperature surfaces should be sent to the Commission. Legionella report certificate received 1/10/06 Mary Street DS0000017013.V308280.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 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 Street DS0000017013.V308280.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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