Inspection on 28/08/07 for Presentation Sisters Care Centre

This inspection was carried out on 28th August 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 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

Presentation Sisters Care Centre 30/01/07

Presentation Sisters Care Centre 31/10/05

Presentation Sisters Care Centre 06/07/05

Presentation Sisters Care Centre 26/05/04

Presentation Sisters Care Centre 01/10/03

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Presentation Sisters Care Centre Chesterfield Road Matlock Derbyshire DE4 3FT Lead Inspector Denise Bate Unannounced Inspection 28th August 2007 09:30 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 Presentation Sisters Care Centre DS0000002072.V342206.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. Presentation Sisters Care Centre DS0000002072.V342206.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Presentation Sisters Care Centre Address Chesterfield Road Matlock Derbyshire DE4 3FT 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) 01629 582953 01629 55140 linda@presentationcare.co.uk The Presentation Sisters Mrs Linda Joyce Monk Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Presentation Sisters Care Centre DS0000002072.V342206.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th January 2007 Brief Description of the Service: The Presentation Care Centre is situated on the outskirts of Matlock, where a range of local amenities and public transport are available. The home provides personal and nursing care for up to 36 residents. Residents are all accommodated in single rooms on three floors of the home. Only one room is en suite, but there is ample provision of bathrooms and toilets. The home is fully accessible for residents and well maintained. There are extensive grounds to the home with magnificent views over local countryside. The home is attached to the Presentation Sisters Convent, but operates independently. There is a complex fee structure and detailed information is available from the administration manager. The fees for this home at the time of inspection ranged from £363.85 to £609.75 (including nursing contribution). There are additional variable charges for hairdressing, chiropody, some incontinent equipment and newspapers. Information about the extra charges are given in each residents letter of contract. There are notices informing residents and their advocates that the inspection report is available from the main office and from the nurses offices. Presentation Sisters Care Centre DS0000002072.V342206.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over seven and a half hours. During the inspection six residents, two relatives, and five staff members were spoken with. The manager and administration manager were present during the inspection and provided assistance and information. Prior to the inspection a number of sources of information were looked at including the home’s service record and previous inspection reports. An Annual Quality Assurance Assessment (AQAA) was completed by the manager prior to the inspection and information provided has been used in the preparation and presentation of this report. Ten residents completed surveys (some with help from relatives), which provided additional information and comments on the home, some of which are also included in this report. A number of records were examined on the day of inspection, including care planning documentation, minutes of meetings, regulation 26 visit records, staff files and medication records. Three residents were case tracked and care planning documentation and files for other residents were seen. A tour of part of the building took place and the grounds were seen. What the service does well: Presentation Sisters provides a comfortable and caring environment for both residential and nursing residents. Residents and relatives spoken with made positive comments about the home and staff; the staff are exemplary, excellent care is provided, I am very happy with my mum’s care. Communal areas of the home are comfortable and provide a range of areas for residents to use. The home was found to be well maintained and clean throughout. The food was said to be ‘very good’ and the quality was praised. The home have a thorough and comprehensive admissions system. Care plans are detailed and reflect the wide range of needs the home can meet. Staff spoken with were enthusiastic, experienced, knowledgeable, and committed to the welfare of residents. There is a core staff group who work well as a team. Staff appraisal takes place and training is given a high priority. Most care staff are trained to NVQ level 2. This ensures that residents needs are well met by staff who are trained and competent to do their jobs. Each floor has a senior care assistant with NVQ level 3. The home is managed by a management board which meets regularly and there is a clear structure of responsibility and decision making. The manager Presentation Sisters Care Centre DS0000002072.V342206.R01.S.doc Version 5.2 Page 6 and administrative manager are supportive and forward looking, providing effective leadership to staff. There is a robust system for recruiting and training new staff and appropriate checks are carried out. A quality assurance exercise found that the overall quality of care was rated as ‘good’ or ‘excellent’ by residents and their advocates. The care centre is attached to Presentation Sisters Convent. A substantial number of residents have chosen the care home as the place most suited to meeting their spiritual needs. What has improved since the last inspection? What they could do better: No requirements were made at this inspection. Some good practice recommendations were made relating to information sharing and staff supervision. The home have plans in place to provide new soffits and facias for St Saviours wing, install a new phone system and a new electricity generator in case of electricity failures. The home plan to continue to develop training, including team leadership for senior carers and other staff, and updating safeguarding adults training for all staff. Please contact the provider for advice of actions taken in response to this Presentation Sisters Care Centre DS0000002072.V342206.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. Presentation Sisters Care Centre DS0000002072.V342206.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 Presentation Sisters Care Centre DS0000002072.V342206.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available to ensure residents can make an informed choice about where they live. EVIDENCE: Information was obtained from the manager and administration manager, discussions took place with residents and relatives, and completed CSCI resident surveys were looked at. This indicated that residents receive enough information about the home before they move in and are able to make an informed choice. Presentation Sisters Care Centre DS0000002072.V342206.R01.S.doc Version 5.2 Page 10 The inspector was shown an information pack given to all prospective residents. This contained a statement of purpose, mission statement, history of the home, a sample contract and visitor information. All residents get a ‘Resident’s Letter of Contract’ that details invidiual fees and conditions on contract. A period of 4 weeks trial is offered to all residents. There is a complex pricing system as the home contracts for residential, nursing and continuing care with a variety of agencies (e.g. local authorities, Primary Care Trusts) as well as with privately funded individuals. There are price variations depending whether the resident is privately funded, or which agency (if any) are providing financial support. The administration manager meets with all prospective residents and/or their advocates to explain the pricing structure. The Inspector was informed that, as a charity, Presentation Sisters Care Home reserved the right to negotiate individual prices where it feels this is appropriate. A good practice recommendation has been made to make written information available detailing the principles on which the pricing structure is based. Extra charges are clearly identified in the home’s literature and on contracting documentation. The administration manager is available to provide clarification if needed. A needs assessment was in place in the three files examined for case tracking purposes; this was detailed and covered all aspects of the persons’ health and social care needs at the time of their admission, including a summary of their medication and any known allergies. Presentation Sisters usually has full occupancy and a waiting list. The inspector was informed that the home has an excellent reputation locally and, as mentioned previously, many residents choose Presentation Sisters because their spiritual needs can be met. A resident commented; several of my friends and relatives have been here and have always been satisfied with the care given. Presentation Sisters Care Centre DS0000002072.V342206.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, 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are completed and are individualised to demonstrate that residents’ health, personal and social care needs are being met. EVIDENCE: Three case tracked residents had clearly arranged care planning documentation. There were detailed care plans in place that provided guidance to staff on the level of support and care required to meet each individuals needs. Many residents have varied and complex needs. Care plans are usually written by professional nursing staff and had general guidance on specific needs. and information and guidance that was personal to each resident. This ensured that every aspect of care was covered in detail. Daily logs are kept. Presentation Sisters Care Centre DS0000002072.V342206.R01.S.doc Version 5.2 Page 12 Information seen on care plans included allergies, the resident’s perception of heath status, carer preference, preferred routine and social history. Care plans seen had been reviewed on a monthly basis to ensure that any changing needs could be identified and met. Not all care plans had been signed by the resident or their advocate. Risk assessments were in place. These assessments were person centred and included assessments on; bathing, use of moving and handling equipment, wheelchair use, cot sides on beds, wound assessment, mobility, falls and history of falls, nutrition, weight, skin condition and pressure areas and a pain assessment tool. The three care files seen demonstrated that residents health care needs were met and all residents had access to health care services, this included dentist, optician, general practitioner, chiropodist and other health care specialists as required. A resident commented: I have found the medical support I have received from the doctor and the nurses very good. The manager said: health care needs are clearly identified and our staff liase with other providers (usually the NHS) to ensure that these needs are met.There is a very good relationship with local GPs , district nurses care managers and other social services staff. There is a communication book which ensures that all matters relating to the day to day care of residents are noted and acted upon. The role of senior carers is being developed to include an element of team leadership and it is expected that this should have a positive impact on the care provided in the coming year. There is a very strong caring ethos in the home, underpinned by Christian principles, which are detailed in the Mission Statement. A relative commented that not only was the physical care of residents very good, but that staff also created a ‘lovely atmosphere’, and included everyone in special events. All of the residents spoken with confirmed that staff treated them respectfully and maintained their privacy when providing personal care and at any other time. Residents and relatives made the following comments; I am very happy here, it is very comfortable, I am always made welcome when I visit, staff look after me very well. The manager said: Privacy and dignity are important elements of care which go to the heart of the care centres philosophy of care and are wholly promoted and respected. The guiding Ethos of the Presentation Sisters means that we respect all of our residents as individuals and care for them unstintingly. There are two medication rooms. The homes medication is supplied by Boots on a monitored dose system. There is a good relationship with the supplying pharmacist who visits and inspects regularly. Some medication administration Presentation Sisters Care Centre DS0000002072.V342206.R01.S.doc Version 5.2 Page 13 records for case tracked were examined and only one gap found, the remaining entries had been recorded appropriately. Most MAR sheets had the photos of the residents, although one was needed for a resident recently admitted. Signatures are being updated as an agency nurse is currently working at the home. The care centre is owned by a religious organisation and their approach ensures that matters relating death and dying are sensitively handled. The management board review the home’s approach on a regular basis. The home follow a recognised ‘pathway’ in their nursing and care of terminally ill residents and their families. Discussion with residents indicated that they could be confident that their wishes would be respected. Presentation Sisters Care Centre DS0000002072.V342206.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 good. This judgement has been made using available evidence including a visit to this service. The home provides suitable activities and the quality of catering is good which contributes to a pleasant atmosphere and the overall levels of satisfaction for residents. EVIDENCE: There is a programme of events provided by First Taste and two activities coordinators are employed who tailor activities according to individual needs and abilities. Some residents prefer to use their rooms as bed sitting rooms and persue their own interests, or not be involved in activities. Some residents are not able to express their views due to their frailty and/or communication difficulties. The manager commented: The increasing dependency and therefore frailty of residents does mean that the level of activities can be relatively low level for most residents. This affects the communal nature of what can be provided. However, residents and relatives spoken to indicated Presentation Sisters Care Centre DS0000002072.V342206.R01.S.doc Version 5.2 Page 15 that their individual preferences were met. The home are planning further work with First Taste to expand the range and type of activity on offer. Visitors said they were made welcome, and two relatives spoken to visited very regularly. The manager said that community contact was encouraged, and they were hoping to increase the number of volunteers at the care centre. There is a formal fundraising committee, including respresentatives of residents and relatives, which raises money for residents amenities and agrees how this is spent. Several residents spoken to had chosen Presentation Sisters because it enabled them to continue being part of a religious community, or to practice their religion in a way that met their spiritual needs, e.g. by being able to attend mass regularly. There is a pastoral worker whose role is befriending residents and helping them in whatever way is appropriate to that individual. Staff can also benefit from this service. There is a weekly ‘trolley shop’ where residents can buy toiletries, sweets etc. Residents and relatives spoken with said the meals in the home were of a very good standard, varied and appetising; the food is excellent, they make very good home made soups, I like the home made cakes, staff always encourage mum to eat and offer her alternatives, like one would get in a five star hotel. There is a four-week menu with a choice of main courses and a vegetarian choice every day. The chef encourages residents to comment on the meals and their suggestions and preferences are taken into account when planning the menus. Special diets are catered for. Presentation Sisters Care Centre DS0000002072.V342206.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): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear and accessible complaints and safeguarding adults procedures are in place to ensure residents can be confident that any issues raised would be acted on effectively and promptly. EVIDENCE: A complaints procedure is in place which indicates that, in the event of a complaint, a response will be given within given timescales. No complaints have been received by the CSCI and no formal complaints have been made to the home. The manager said: we take complaints very seriously and these are investigated and answered thoroughly. The number of complaints is very low and are therefore given deep consideration particularly if there are matters which can be improved. Minor complaints and concerns are raised with staff or the manager and dealt with at the time; these would generally be recorded in the communication book. The manager said: we work hard to ensure that the rights of our residents are upheld and that they live in a protected environment. There are policies and procedures in place for safeguarding adults. The manager is now an accredited Presentation Sisters Care Centre DS0000002072.V342206.R01.S.doc Version 5.2 Page 17 trainer on safeguarding adults and all staff will have updated training on these matters. Safeguarding adults was discussed in detail with the manager who explained that two situations had arisen where discussions with social services had taken place. Staff spoken to were aware of issues relating the the abuse of vulnerable people and indicated they would seek advice appropriately. Presentation Sisters Care Centre DS0000002072.V342206.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, 21, 22, 24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides residents with an attractive, safe and homely place to live. EVIDENCE: The home is arranged in three areas, each with its own lounge, toilets and bathing facilities. A tour of part of the premises was undertaken and the environment appeared well maintained throughout. Residents and relatives felt that the facilities were good and on relative commented: there are lovely grounds. Presentation Sisters Care Centre DS0000002072.V342206.R01.S.doc Version 5.2 Page 19 There is an in -house maintenance team who undertake regular and programmed work. Recent work undertaken has included replacing heating boilers, replacing some windows and an external patio awning has been installed for use in fine weather. The home plan to improve the entrance area, provide new carpets in some communal areas with new furniture and curtains in a residents lounge. Soffits and fascia boards are being replaced on parts of the building. The new legislation relating to smoking has been implemented and a decision recently taken that the home will be a smoke free site . Some residents’ bedrooms were seen. They had been decorated to a good standard and rooms demonstrated individual preference and taste. Residents were able to bring their own furniture such as televisions with them if they wished to. Residents spoken with expressed their satisfaction with their bedrooms, several of which had lovely views over the countryside. There is an excellent range of bathroom facilities with various assisted baths. The manager said; the home invests in specific equipment as required for individual residents (eg specialist chairs, wandering alarm systems etc) Liaison takes place with the Community Occupational Therapist on these occasions. Hoists were available in all areas. A variety of individuals discussed the specialist equipment available to them, including wheelchairs and special beds. All areas of the home were clean and tidy on the day of inspection. A member of the domestic staff said that the standard of equipment provided is good. Relatives commented, the home is always clean and is decorated very nicely, cleanliness is outstanding. Control of infection procedures have been examined and are being reviewed in accordance with Essential Steps (recently published guidance). Presentation Sisters Care Centre DS0000002072.V342206.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): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A trained and competent workforce are in place which meet the dependency needs of residents currently accommodated within the home. EVIDENCE: On the day of inspection there were sufficient care staff to meet the needs of residents accommodated within the home. The current rota has two care staff on each floor (a total of six), two trained nurses in the mornings, and a trained nurse in the afternoons and at night. Staff are usually very busy, but both staff and residents feel there are usually sufficient staff on duty to deal with most situations. The manager said that dependency levels are monitored on an on going basis and extra staff brought in when necessary, e.g. for continuing care. Several staff have been on sick leave and some shifts have been covered by agency staff. This has been working satisfactorily and the manager said they have been able to cover all shifts. Presentation Sisters Care Centre DS0000002072.V342206.R01.S.doc Version 5.2 Page 21 Five staff were spoken with, including domestic and catering staff. Staff are proud of the standards of care they provide in all areas and feel they get good support; we get on well and help each other, we were very pleased to get the Investors in People Award, communication is generally good. Staff spoken with were aware of the rights of residents; they have the same rights as us, we put the residents first. Staff recruitment and training records were seen for three members of staff. All of the required documents were in place to demonstrate that staff had undergone the required employment checks and that induction and mandatory training had been undertaken and was up to date Members of staff spoken with commented that the training opportunities were good; there are lots of courses that give you the skills to do your job. One member of staff had recently taken up her post and said that the induction, training and support from the manager and colleagues was good. As already mentioned, the home have achieved the Investors in People Award. Training undertaken by staff includes mandatory training (fire, basic food hygiene, moving and handling) and other skills, e.g. dementia care. Future training planned includes safeguarding adults updates and infection control. Staff have the opportunity to progress and take on additional responsibilities e.g. two members of staff spoken with had recently had team leadership training. As mentioned previously, the home plan to increase the responsibilities of some senior care staff. Ancillary staff also undertake appropriate NVQ training. The home has a very detailed annual appraisal system, and examples were seen on staff files. Other supervision tends to be informal and to occur when staff are carrying out their day to day duties. It is recognised that a more formal recorded system of supervision could be introduced. Presentation Sisters Care Centre DS0000002072.V342206.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): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is suitably qualified and experienced and staff demonstrate an awareness of their roles and responsibilities, thus ensuring the home is run in the best interests of residents. EVIDENCE: The registered manager is a registered nurse and has achieved the required management qualifications and has nearly completed a level 5 Introductory Diploma in Management. The training and development undertaken by the Presentation Sisters Care Centre DS0000002072.V342206.R01.S.doc Version 5.2 Page 23 registered manager demonstrated that she updates her skills, knowledge and competence. The home also has an administration manager who manages ancillary services and other areas not directly related to care. She has completed a level 5 Introductory Diploma in Management. There are clearly defined roles for each manager and they work well as a team. There are clear lines of accountability within the home and also via external management arrangements. Staff spoken with said they could discuss any problems or difficulties with the managers; we try and resolve problems, but can go to the line manager when we need help. The inspector was informed that regular staff meetings are held. The chairman visits fortnightly and these visits are documented. Copies of regulation 26 visits were seen and indicate that matters relating to the day to day running of the home are dealt with appropriately and promptly. The manager said: there are numerous Quality Assurance measures, both formal and informal, in place. As a charity the Care Centre has particularly demanding financial policies and procedures including external accountants and annual audits. The results of last year’s quality assurance exercise was seen and indicated a high level of satisfaction. Another questionnaire is due to take place in the near future. The inspector was informed that the home has a manual system for managing residents’ personal monies which appears to work satisfactorily. The system was demonstrated to the inspector; signatures for expenditure are made and all receipts kept. The information provided by the manager prior to inspection indicates that the home makes every effort to ensure safe working systems are in place and equipment maintained satisfactorily. Presentation Sisters Care Centre DS0000002072.V342206.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 x 4 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Presentation Sisters Care Centre DS0000002072.V342206.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 OP1 Good Practice Recommendations Detailed fee information should be made available for prospective residents and their advocates in a written format to provide transparent information on the range of fees. Residents or their advocates should sign care plans to contribute to evidence that discussions take place on how each individual’s care is to be provided. Formal staff supervision should take place within the recommended timescales. 2. 3. OP7 OP36 Presentation Sisters Care Centre DS0000002072.V342206.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Presentation Sisters Care Centre DS0000002072.V342206.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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