Inspection on 16/05/07 for More Hall Convent

This inspection was carried out on 16th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

More Hall Convent 28/02/06

More Hall Convent 23/11/05

More Hall Convent 16/02/05

More Hall Convent 02/11/04

More Hall Convent 25/02/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE More Hall Convent Randwick Stroud Glos GL6 6EP Lead Inspector Mrs Janet Griffiths Unannounced Inspection 16th May 2007 09:45 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 More Hall Convent DS0000016504.V331040.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. More Hall Convent DS0000016504.V331040.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service More Hall Convent Address Randwick Stroud Glos GL6 6EP 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) 01453 764486 01453 764486 moorehallconvent@tiscali.co.uk Grace & Compassion Benedictines Sister Elsy Poonoly Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places More Hall Convent DS0000016504.V331040.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2006 Brief Description of the Service: The Sisters of the Order of Grace and Compassion Benedictines run this Care Home. Although the Order is Catholic, any denomination is welcome at More Hall. The Sisters care for the elderly person who requires help and supervision with their personal care and daily activities. The Home is well maintained and run in a way that takes into account the residents’ ideas and preferences. Accommodation consists of single bedrooms and ample communal rooms, including bathrooms and toilets. There are attractive gardens, which are enjoyed in all weathers and ample car parking. The Home is ‘wheelchair friendly’ and has a shaft lift for access to the first floor. There is also a ramped entrance to the side of the building. At the time of inspection the fees range from £320.00 to £380.00 per week. Additional charges are made for hairdressing, chiropody, newspapers and toiletries. People funded through the Local Authority have a financial assessment carried out in accordance with fair access to Care Services procedures. Local Authority or Primary Care Trust charges are determined by individual need and circumstances. General information about fees and fair terms can be accessed from the Office of fair trading web site at www.oft.govuk http:/www.oft.gov.uk More Hall Convent DS0000016504.V331040.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This unannounced key inspection site visit took place over eight hours on two days in May 2007. During this time the inspector spoke to a number of residents, one relative, staff working in the home and the manager of the home. A tour of the premises took place. Most of the bedrooms and all the communal areas were seen during the course of the two days. Four resident’s files were examined in detail to include their medication records. Other records examined included policies and procedures and staff recruitment and training records. Surveys were sent to service users, relatives and staff prior to the inspection and the results were collated and fed-back at the end of the inspection. A pre inspection questionnaire was sent out several weeks before the inspection and returned to CSCI. An Annual Quality Assurance Assessment (AQAA) form was also completed. Information from these were used when completing the site visit and writing the report. What the service does well: The home offers a peaceful and homely environment run by a very caring team of nuns and care staff. The residents are genuinely afforded autonomy and are able to express their views and concerns freely. The home provides spiritual support and guidance to those residents whose faith is central to their lives and committed care to those who may not have a particular faith. All are afforded a high degree of privacy. When asked in the surveys what the home does well, the following responses were received from relatives: ‘Always, this unit is well administered run by sisters and staff. The home always smells fresh and clean and the turnover of fresh faces in the sisters community makes for extra interest and harmony in my view’. More Hall Convent DS0000016504.V331040.R01.S.doc Version 5.2 Page 6 ‘ The care, trips to the medical centre, outings and spiritual well-being are catered for very well’. ‘ The nuns are very communicative, sympathetic and kind; the atmosphere is very caring at More Hall. the meals are good, with good seating arrangements for the residents’. ‘ Staff generally attentive. My mothers lack of mobilty is a problem to her which is frustrating and dispiriting. it would be good if some facility could be made available to take them out on occasions-special transport arrangements’. ‘The care home provides a close , and caring environment for the health and well-being of all the residents. Importantly the home provides for the spiritual needs of the residents. There is always a feeling of close personal contact and love for the residents by a dedicated staff’. ‘The home shows real care and respect for the individual person. The level of support is exemplary with regard to my aunt.- every effort is made to her needs to ensure she is kept well and secure in her environment’. And from staff: Friendly and family atmosphere; treats service users as individuals and is keen to maintain this;.the care home treats all well; I am impressed at how the Convent strives to create a homely environment for the residents; the support from other service users; the sisters are always concerned about the residents and their welfare; Outings and entertainment. What has improved since the last inspection? What they could do better: Ensure that a care plan is in place for any problems identified. All records to be completed in black ink, signed with a full signature and tippex must not be used. Please contact the provider for advice of actions taken in response to this More Hall Convent DS0000016504.V331040.R01.S.doc Version 5.2 Page 7 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. More Hall Convent DS0000016504.V331040.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 More Hall Convent DS0000016504.V331040.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 and 3. Standard 6 not applicable. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective residents and their families have all the information they need to make an informed choice regarding placement at the home, and pre-admission visits take place. Needs are assessed by the manager prior to and following admission. Residents normally move in on a long-term basis therefore Std. 6 was not assessed More Hall Convent DS0000016504.V331040.R01.S.doc Version 5.2 Page 10 EVIDENCE: The home has a comprehensive Statement of Purpose, and a Service Users Guide, a copy of which is given to each resident/ their relatives on admission. This is reviewed regularly and any changes made. From surveys received, all confirmed they had been given enough information about the home prior to admission. There have been no new admissions since the last inspection and the home currently only has nine residents accommodated with two more in hospital. Most of the residents were spoken with and confirmed that they were very happy living in the home. One relative also spoken with confirmed that she was very satisfied with the care provided and said her father was very happy at the home, a statement which he agreed with. The manager always sees each prospective resident prior to admission and carries out an assessment. This ensures that the home would be able to meet their needs. Pre-admission records were seen. More Hall Convent DS0000016504.V331040.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. Individual care plans clearly set out needs and how they are met to include healthcare referrals and interventions where required. Systems are in place to ensure health care needs are met and that medication is appropriately handled. Those living in the home are treated with respect; their privacy and dignity are protected. EVIDENCE: Four care files were examined at this inspection. More Hall Convent DS0000016504.V331040.R01.S.doc Version 5.2 Page 12 Most clearly identified individual care needs and how these should be met, and the care plans reflected the current needs of these residents. One exception to this was where someone had been assessed as at risk of pressure sores. The district nurse closely monitors this resident and pressure relieving mattress and cushion were in place, but there was no care plan to document this. Care plans are reviewed regularly and although residents and their relatives do not always take part in care plan reviews, they are all kept fully informed of, and given the opportunity to discuss any changes. Staff spoken with demonstrated that they were fully aware of all of the resident’s needs and how they could meet them. They were kept fully informed on a day- to- day basis through care plans and handovers and someone is delegated to write the daily records each day. However, one night carer did state that they would have preferred to see the care plans before meeting the residents in order to have some background information. Residents and relatives’ surveys also confirmed that they felt their needs were met. When asked if they receive the care and support they need? The responses were all positive. Residents and staff spoken with, and the care records, all confirmed referral and intervention from health professionals where necessary. Doctor’s visit the home on request. The district nurses are currently visiting one resident weekly to apply wound care and another had some blood tests the day of inspection. Wherever possible residents go out to visits the chiropodist, dentist and optician. Otherwise consultations are arranged in the home. One resident reported that she is due to visit the hospital for an assessment prior to eye surgery. The home states in its brochure and service users guide that ‘they have strong Christian values and believe that their residents should be able to choose their own way of life in so far as is possible’. Their aims and objectives include, ‘respecting your privacy and dignity, ensuring that as a senior citizen, perhaps with some disability, you are treated with positive attitudes’. Residents spoke with confirmed this and observations showed residents being addressed respectfully, and staff knocking on doors before entering rooms. Where they are able residents also have keys to their rooms and to the front door, enabling them to come and go as they please and to maintain their privacy. Residents, where appropriate, may be responsible for their own medication and are protected by the homes’ medication policy. More Hall Convent DS0000016504.V331040.R01.S.doc Version 5.2 Page 13 Two residents are currently self-medicating. Risk assessments are completed and reviewed regularly and lockable drawers are provided in their rooms. Medicines are supplied via a Nomad cassette system and printed medication records, delivered regularly by the local pharmacy. All staff who administer medicines have received training in the use of this system of administration. The care manager regularly audits the medication administration and policies and procedures are in place. Two other staff, called ‘infirmarians’ are responsible for the ordering and return of unwanted medication and liaison with doctor’s and other health professionals. Medication records were examined and were well maintained, with one or two exceptions where red ink to record a handwritten transcription and tippex had been used. These are not acceptable and must cease. The home keeps a British National Formulary (BNF), but this was dated 2005 and they were advised that a more up to date copy should be obtained. More Hall Convent DS0000016504.V331040.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home caters for a wide range of individuals who are supported to realise their own preferences and expectations, both in the home and in the community. Maintaining contact with friends and family is supported by the home. Residents receive a wholesome, appealing and balanced diet in pleasant and comfortable surroundings. EVIDENCE: The residents spoken with, and their surveys, confirm that they retain as much control and freedom over their lives as is possible for them. More Hall Convent DS0000016504.V331040.R01.S.doc Version 5.2 Page 15 Many have chosen the home for the spiritual support it offers to a multidenominational community. The home has its own chapel where mass is held daily for those who wish to attend. It is actively used by the local community, but ministers from other faiths, such as Anglican and Quaker, visit and are joined in their worship by residents from other faiths. Most of the residents spoken with recounted their trip on the Willow Trust narrow boat the previous day and said what a lovely day they had had. Previous outings have included trips to Blooms garden centre and Bristol Zoo. Weekly shopping trips also take place, and one resident accompanied by one of the sisters returned from one on the second day of inspection. Two residents have their own pet cats, which are a great comfort to them. Visitors are always welcomed and links with the community well maintained. The home has recently formed a ‘Friends of More Hall’ group made up of residents, relatives and members of the local community and one of their functions is to organise fund raising events and then determine how these funds are best spent to benefit the residents. Some of these funds financed the boat trip and a green house for the garden is the next project. There were two comments in the surveys related to residents’ inability to take part in activities and outings because of disabilities: ‘Not possible due to blindness’. ‘ Mother’s lack of mobility is a problem to her that is frustrating and dispiriting. It would be good if some arrangement could be made available to take them out on occasions-special transport arrangements. The manager reported that any aids to help sight disability are provided such as talking books and clock and suggestions of craft activities have been explored but rejected. Special transport arrangements are made on occasions to take residents out, and the home does go out on a number of outings. Provision of a new lighter wheelchair is currently being organised. As many of the sisters are from overseas, one of the fund raising events that has been very popular in the community is to have a ‘curry evening’, where the local community can come and enjoy a curry, cooked by the sisters, at the home with the residents, or can purchase and take away. This event has proved very popular and has greatly increased the funds, so that there are plans to repeat the event once or twice a year. Residents may enjoy curry once a week if they wish, but alternatives are always available. There were a number of negative comments related to the meals in the home, in the surveys received and in the homes own surveys, but the cook has left since then and until a new cook has been appointed the nuns More Hall Convent DS0000016504.V331040.R01.S.doc Version 5.2 Page 16 are cooking, and the residents all confirmed they are happy with the meals at present. Some of the comments were as follows: ‘The ingredients are good but the cook leaves a lot to be desired’, and ‘Cooking can spoil good quality food’. One relative stated: ‘Lunches and suppers could be a lot better’. And staff surveys suggested that residents should have a greater choice of desserts and could be involved in choosing a cook and menu planning. A new summer menu has been planned in preparation for the new cook and all the residents have seen this and have been able to make their comments/contributions. Menus are displayed on a board each day and one resident explained: ‘The nuns are always ready to provide something different if they are asked. The menu for the day is put up at breakfast time. If any of us want something different it is of course a help if we let them know well before lunch, otherwise we get what we have requested after a short wait’. Special dietary needs are catered for as one lady who is diabetic confirmed and assistance is offered where required as observed when one resident who requires a soft diet and supervision to ensure that she is able to manage, had a carer sat beside her through her meal. More Hall Convent DS0000016504.V331040.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems within the home protect the interests of residents. EVIDENCE: The home has a complaints procedure included in the service users guide. Surveys received all confirmed that they know how to complain with comments such as: ‘I’ve never had to make one’ and from one relative: ‘ I have the name of the contact at Glos SSD’. The pre inspection questionnaire reported that they had received 10 complaints since the last inspection, and a record was kept of each one with details of action taken. The manager reported that she reports every incident and the complaints ranged from when the police were called because someone had put fireworks through the letter- box, to complaints from the community about overhanging branches and a bonfire in the grounds. More Hall Convent DS0000016504.V331040.R01.S.doc Version 5.2 Page 18 All of these had been issues dealt with satisfactorily by the home. Staff interviewed all confirmed that they had either been or were about to go on Adult Protection training and understood what is meant by whistle blowing and the various forms of abuse. Policies on adult protection and whistle blowing are in place and were reviewed in January 2007. More Hall Convent DS0000016504.V331040.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well maintained, clean and hygienic throughout. Individual bedrooms are decorated and equipped to meet the needs of their occupants. EVIDENCE: As this was the inspector’s first visit to this home a tour took place. The home has a calm and peaceful atmosphere. Everywhere was well maintained and in good decorative order. More Hall Convent DS0000016504.V331040.R01.S.doc Version 5.2 Page 20 The home has a rolling programme of maintenance work and decoration. Since the last inspection the dining room, sitting room and some bedrooms have been redecorated. Rooms are always redecorated and re-carpeted as they become empty. Automatic taps have been fitted in two rooms and a shower in one bathroom on the mezzanine floor. An extractor hood has been fitted in the kitchen. All Sisters within the convent are responsible for keeping the care home clean. All areas are exceptionally clean and good infection control is practiced. Plastic aprons and gloves are available as required and clean aprons are worn when serving food. Comments in the surveys on the cleanliness in the home stated: ‘The Sisters are very particular’; ‘Exceptionally’; ‘Some residents can leave bathroom dirty and floor wet especially at night’. ‘The home smells fresh and clean’. More Hall Convent DS0000016504.V331040.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29, & 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has sufficient staff who are skilled to meet the needs of those living at the home. Service users are protected by the homes recruitment system. Staff are supported to undertake regular and relevant training. EVIDENCE: The manager and nuns live on the premises and care staff are on duty 24 hours on a rota system. During the day both nuns and care staff are on-duty and at night one member of staff is on ‘waking’ duty and another member of staff is always on call and can be summoned by a pager. There were more than adequate staffing levels during the inspection visit, staff were observed working in a calm and unhurried manner and there were no residents observed waiting for attention. More Hall Convent DS0000016504.V331040.R01.S.doc Version 5.2 Page 22 Staff turnover is low and there is a good staff ratio to service users at all times. Resident’s surveys stated that staff are available when they need them, all said they get the care and support they need and that staff listen to them and act on what they say. Eight staff (90 ) have NVQ level 2 or above. All staff spoken with are very committed to training and development and all have completed some training within the last 12 months. This includes mandatory updates in moving and handling, first aid and food hygiene and specialist training such as continence care. The home also has a wide range of instructional videos on a wide range of subject to include fire safety and dementia. Future training planned includes POVA, dementia awareness, nutritional problems, health and safety (for the maintenance man), first aid, moving and handling and food safety. Staff files contain a record of training completed and certificates to confirm this and staff surveys confirmed that the home provides funding and time to receive relevant training. One stated: ‘The staff strive to provide teaching sessions for staff, i.e. fire lectures, continence advice- there are also a range of videos pertinent to care homes that staff are encouraged to watch’. All newly appointed staff undertake a staff induction, in line with Skills for Care. Records and surveys confirmed this. The home has a robust recruitment procedure in place for both those who do not belong to the religious community, and the nuns. A selection of staff files were seen and all had the required documentation and checks to include criminal record (CRB) and protection of vulnerable adults (POVA) checks. The homes’ application form does not currently offer a declaration of the persons physical and mental fitness- staff currently handwrite such a declaration. This is to be addressed. It was also advised that a standard format interview record should be kept. The manager was also advised that once CRB’s have been seen and checked by the inspector they can be shredded in line with data protection requirements. More Hall Convent DS0000016504.V331040.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32, 33,35, 36,37 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well run by the manager who is committed to her responsibilities. Her approach is open and inclusive. The home is run in the best interests of those living here. Systems are in place to protect both residents and staff. EVIDENCE: More Hall Convent DS0000016504.V331040.R01.S.doc Version 5.2 Page 24 Since the last inspection, the Commission has approved the former deputy manager, Sister Elsy, as registered manager for the home. She has completed the registered managers’ award and is currently undertaking NVQ 4 in care. Living on the premises she offers constant managerial support. She has been caring for the elderly for many years and gained valuable management experience in her role as Deputy. She is very popular with the residents and staff alike. Staff surveys stated that they all felt well supported by the manager and confirmed that they have regular supervision and meetings. The home has a quality assurance programme in place and provided a report and action plan from the last satisfaction survey completed in March 2007. One of the comments raised was that residents felt there were not enough toilets especially at peak times. For 9 residents currently, the home has 8 toilets, and is seeking to explore the possibility of providing some en suite facilities but as the main home is a listed building this may be difficult. The registered provider also carries out an unannounced visit to the home on a monthly basis to ascertain the views of the residents and to ensure the home is running smoothly. A written report is subsequently submitted to the CSCI each month. Arrangements are in place for the safe keeping of small amounts of money for certain residents. Records are kept of any financial transaction undertaken and a random selection of these records was examined. Records of staff appraisal and supervision were seen and staff confirmed that they received this. Policies and procedures are in place and have been reviewed and updated. Daily records are kept and recorded at each shift. These were found to be detailed and informative and demonstrated action taken when any untoward incident was reported. Staff were reminded that as legal documents all records should be signed with a full signature. Accident records are also kept and are audited regularly. Records seen confirmed that regular servicing and maintenance of equipment is completed. More Hall Convent DS0000016504.V331040.R01.S.doc Version 5.2 Page 25 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 4 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 4 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X 3 3 3 4 More Hall Convent DS0000016504.V331040.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation 19(4)(a) Schedule 3 Requirement The registered person must ensure that all new employees are fit to work at the care home and evidence that the person is mentally and physically fit to work. Timescale for action 30/06/07 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. 3 Refer to Standard OP8 OP37 OP29 Good Practice Recommendations Where someone is identified as at risk of developing pressure sores appropriate intervention is recorded in the care plan. All records to be made in black ink, signed with a full signature and not altered by using correction fluid (tippex). A record of interview to be kept as part of the recruitment process. More Hall Convent DS0000016504.V331040.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 More Hall Convent DS0000016504.V331040.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!