Inspection on 30/01/07 for Presentation Sisters Care Centre

This inspection was carried out on 30th January 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 28/08/07

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 Judith Beckett Unannounced Inspection 30th January 2007 10:30 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.V325580.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.V325580.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 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.V325580.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To allow Presentation Sisters to accommodate one named individual under 65 (named in notice of proposal) 31st October 2005 Date of last inspection 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. The fees for this home range from £308.15 to £453.30. There are additional variable charges for hairdressing, chiropody, incontinent equipment and newspapers. Presentation Sisters Care Centre DS0000002072.V325580.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in January 2007. It is the first inspection since October 05 so all of the key standards were examined on this visit. The visit lasted for approximately six and a half hours. Discussions were held with the administration manager, the deputy matron, and 2 members of staff, 2 relatives and 4 residents. The manager was on holiday but had completed a very detailed pre inspection questionnaire. 7 completed CSCI resident surveys were received. Inspection methods used included the examination of care records, the case tracking of 2 residents to ascertain how the service works in practice for them and direct observation of care practices. 35 residents were accommodated at the home, 2 were in hospital and 1 new admission due that week, and 28 were assessed as requiring nursing care. Staffing rotas were looked at to assess if the level of staff on each shift could meet the needs of the resident group. Activities provided by the home were assessed and residents’ were asked their opinions on the activities provided. Menus were examined and residents were spoken with to determine the quality and choice of meals provided. Records were examined to determine if the service demonstrated through their staff recruitment and training practices that the welfare and safety of residents was promoted and protected. Two members of staff were also spoken with to seek their views on the support and training provided to them. A tour of the home was undertaken to assess the décor, maintenance and standards of hygiene. Environmental Health had inspected on 18/9/06 and the Fire Officer on 20/6/06. What the service does well: Residents and relatives are suitably consulted with and involved throughout their admission and provided with clear information about the home and its terms and conditions and their needs are effectively assessed and well met. A good standard of accommodation is provided, residents say that the home is comfortable, ‘always clean & fresh’ and well furnished and decorated. Residents comment that staff are ‘kind’, ‘they give me the care that I need’ and that privacy and dignity is maintained. One resident stated ‘ I have been made to feel completely at home’. Resident’s rights to complain are upheld and complaints made are taken seriously and acted upon and they are protected from abuse. There is a pro-active approach and strong commitment to training and people development particularly with regard to achieving NVQ’s. This ensures that Presentation Sisters Care Centre DS0000002072.V325580.R01.S.doc Version 5.2 Page 6 residents needs are well met by staff who are trained and competent to do their jobs. Each floor has a care assistant NVQ level 3 leading the care. Excellent comments relating to the catering were received both from speaking to the residents and feedback from the questionnaires and resident surveys The home is well managed and run in the best interests of service users. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Presentation Sisters Care Centre DS0000002072.V325580.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 Presentation Sisters Care Centre DS0000002072.V325580.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents have the information they need to decide if this is the right place for them to live. Residents can be assured that they have their needs fully assessed before they move into the home and this includes the care to be provided. EVIDENCE: Discussions with residents, representatives and completed CSCI resident surveys indicate that enough information is received about the home before people move in, so that they can decide if it is the right place for them. A folder containing a service user guide and statement of purpose are in place in each room, additional information included are ‘Visitors information’ and ‘Our Catering Services’. 7 completed resident surveys were received, all of which said that the resident had received a contract. 2 relatives were interviewed, one did not deal with the finances of the resident and two residents were interviewed one who dealt Presentation Sisters Care Centre DS0000002072.V325580.R01.S.doc Version 5.2 Page 9 with their own finances. Discussions with residents, their representatives and the deputy manager indicated that the majority of residents did not deal with their own finances. A sample of a resident’s letter of contract was seen. This includes all the required elements as listed in standard 2.2. A Needs Assessment was in place in the 2 files examined for case tracking purposes; this covered all aspects of the persons’ health and social care needs including a summary of their medication and any known allergies. This had been carried out prior to admission by the matron or deputy matron. A period of 4 weeks trial is offered to all residents. Presentation Sisters Care Centre DS0000002072.V325580.R01.S.doc Version 5.2 Page 10 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. Resident’s health, personal and social care needs were set out within their individual plan of care and residents were treated with respect and their right to privacy maintained. The policies and practices in place for dealing with medicines ensured residents safety and welfare was maintained. EVIDENCE: Since the last inspection new care plans had been introduced. These were based on the activities of daily living. Both of the two resident’s care files seen had detailed care plans in place that directed the staff in the level of support and care that was required to meet each individuals needs. All of the care plans seen identified health, personal and social needs and had been generated from each individual’s needs assessment. Evidence was in place to demonstrate that residents’ had been involved in the formulation of their care plans and all care plans seen had been signed and dated by the registered manager. The home should work towards obtaining signatures from residents/relatives on care plans. Presentation Sisters Care Centre DS0000002072.V325580.R01.S.doc Version 5.2 Page 11 Both of the care plans seen had been reviewed on a monthly basis to ensure that any changing needs could be identified and met. Risk assessments were in place within the two residents’ files seen 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. All of the assessments seen were detailed, dated and signed and reviewed on a regular basis, to ensure any changing needs could be identified and met. Daily report sheets were completed and signed. Evidence was in place within the two care files seen that 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. The homes medicines are supplied by Boots on a monitored dose system. All the medication administration records were examined and only one gap had been found, the remaining entries had been recorded appropriately. Some M.A.R sheets had the photos of the residents, newer admissions hadn’t. It is recommended these are completed. All care staff are undertaking training in the safe handling of medicines in order to administer medicines to residential clients. The policies regarding medication were also seen and provided detailed instruction in each area of medication receipt, storage, handling, administration and disposal. 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. Presentation Sisters Care Centre DS0000002072.V325580.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. 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. Various social activities were available to residents and residents maintained contact with family and friends., which promoted their wellbeing. The meals provided in the home were of a high standard ensuring that residents were offered appealing and wholesome choices. EVIDENCE: During the inspection a music and singing session took place and the inspector observed a care assistant playing dominoes with a resident. Comments from the patient questionnaires indicate that activities are sometimes/usually available. One of the residents spoken with had chosen the home because they felt their spiritual needs would be met. One resident was pleased to be able to attend mass every week. There was a programme of activities offered to residents in the home, organised by two part-time activities coordinators working approximately 15 hours per week in total. A pastoral worker is now in place, their role being to befriend residents. Staff can also benefit from this service. Presentation Sisters Care Centre DS0000002072.V325580.R01.S.doc Version 5.2 Page 13 Records were seen of the activities carried out and these included playing dominoes, music and exercise, reading, and crafts. One to one sessions take place and these were seen to be recorded. The records noted which residents joined in and what the response to the activity was. There was a weekly ‘trolley shop’ where residents could buy toiletries, sweets etc. One resident spoken with enjoyed the activities offered. Staff spoken with felt that the activities programme was good and that it could be expanded. The home had a large, well-equipped kitchen which also catered for the convent. The kitchen was clean and well organised. The environmental health dept. had inspected on 19/9/06 and stated in their report that ‘the standard of hygiene and level of hazard awareness being maintained at the premises were found to be very high,’ ‘kitchen and stores were also found to be maintained in good repair.’ Residents and visitors spoken with said the meals in the home were of a very good standard, varied and appetising. All the questionnaires returned indicated the food was excellent, one resident commented that, ‘I order my own meals which I always get’. There was a four-week menu with a choice of main courses and a vegetarian choice every day. The menu was varied and appeared well balanced. There was evidence that residents were encouraged to comment on the meals and that their suggestions and preferences were taken into account when planning the menus. Menus were in the process of being reviewed; carers, residents and relatives were being involved. Presentation Sisters Care Centre DS0000002072.V325580.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. 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. Residents are confident that their concerns will be listened to, taken seriously and acted upon. Policies and procedures are in place to protect residents from abuse. EVIDENCE: A complaints procedure is in place that indicates that a response will be taken in the event of a complaint within given timescales. No complaints have been received by the CSCI and one complaint has been received by the home. The complaint has been responded to and recorded on the communication sheet, with the outcome being communicated to the complainant. It was recommended that an indication of where the details and outcomes are kept should be recorded in the complaints book. Two relatives said that they knew who to speak to if they are not satisfied with something or have any concerns. One relative had raised a matter with the matron and this had been resolved. Residents also said that they would speak to the manager or a member of staff if they were not happy or had any concerns. They also said that they feel confident that they would be listened to and their concern would be acted upon. A copy of the complaints procedure was in each of the bedrooms for ease of reference for residents and representatives. Evidence was in place in staff files to demonstrate that staff had undertaken adult protection training in their induction and continued to do so on a rolling programme to ensure all staff are kept up to date. Presentation Sisters Care Centre DS0000002072.V325580.R01.S.doc Version 5.2 Page 15 The policy relating to Adult Protection was seen and was in line with the local authority guidelines. No adult protection referrals or investigations have been made in the last twelve months. Presentation Sisters Care Centre DS0000002072.V325580.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe well-maintained environment with good standards of hygiene maintained. EVIDENCE: A tour of the premises was undertaken and the environment appeared well maintained throughout. Since the last inspection, maintenance work has continued with a new boiler system, a new roof over the kitchen, a new fire alarm system, new french doors and windows to the second floor and lounge and new door magnets. New equipment has included a freezer, and 3 riser beds. Residents’ private accommodation seen 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 private accommodation. Presentation Sisters Care Centre DS0000002072.V325580.R01.S.doc Version 5.2 Page 17 Hoists were available in all areas. Bathrooms and shower rooms provided adequate space for residents requiring support from moving and handling equipment, such as hoists. Communal areas of the premises were well lit, well ventilated, bright and homely. The laundry area was seen, this is a large area with well defined dirty and clean areas including a chute for dirty laundry, satisfactory equipment and facilities were in place to control the spread of infection. A satisfactory infection control policy was also in place, new anti bacterial hand cleansing dispensers had been installed around the home for use by residents, staff and visitors to reduce the spread of infection. A team of 3 maintenance workers are employed (one full time, two part time). All rooms are decorated on a rolling programme and also when one becomes vacant. Planned for this year are a new generator in case of electricity failures. New soffits and fascias are planned for St. Saviours. As a result of the residents survey a new phone system is to be installed which will result in a reduction of paging over the loudspeaker system. Residents and relatives commented on the intrusion by the paging system presently in use. A no smoking ban is to take place as from April 1st.The staff smoking room will no longer be available for smokers. Presentation Sisters Care Centre DS0000002072.V325580.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. 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. The numbers, skill mix and qualifications of staff demonstrated that a competent staff team could meet the needs of residents. The resident’s safety was promoted by the recruitment practices in place . EVIDENCE: Staffing rotas provided indicate that the home is staffed in accordance with recommended guidance to meet with the assessed needs of residents. All of the residents spoken with say that staffing levels are generally satisfactory and there is a member of staff available if they need help with anything. Although one questionnaire commented that ‘often staff are too busy to do more than the bare necessities’. There were 35 residents accommodated on this visit, with 28 residents being assessed as having nursing needs and 7 residents with personal and social care needs. It was noted that over the Christmas period many of the nursing patients required a high level of care. The home does take into account the level of care required when new admissions are planned. Staff recruitment and training records were seen within two staff files, 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. All staff files now have photographs of staff. Presentation Sisters Care Centre DS0000002072.V325580.R01.S.doc Version 5.2 Page 19 The training undertaken at the home in the last twelve months included; moving and handling, basic food hygiene, health & safety, administration of medicines, fire training and NVQ 2 and 3 training. Two members of staff were spoken with to ascertain their opinions on the training and support provided. One member of staff had recently taken up her post and stated that the induction training and support from the manager and senior staff that she had received was good. The other member of staff confirmed that training was provided on an ongoing basis and confirmed that the support by the manager and senior staff was good. Sixty- two staff are employed at the home. Of these sixty-two, thirty- one are care staff. There is a strong commitment to NVQ training with over 67 of care staff having achieved NVQ level 2 or above. The home therefore exceeds the standard in this area. Five catering staff had commenced the nutrition in health training course, which covers nutrition for the elderly and special diets. Three housekeeping staff have completed N.V.Q 2 in housekeeping. The head housekeeper has completed an infection control course. A development plan for all training to take place this year was seen. Staff appraisal forms have now been introduced and appraisals are documented. Presentation Sisters Care Centre DS0000002072.V325580.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. 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 good management practices and the safe working practices in place at the home maintain residents’ health, welfare and safety. EVIDENCE: The registered manager is a registered nurse and has achieved the required management qualifications and is presently studying for a level 5 Introductory Diploma in Management. The training and development undertaken by the registered manager demonstrated that she strives to update her skills, knowledge and competence. The home also has an administration manager and there are clear defined roles for each manager. The Chairman visits fortnightly and these visits are documented. Discussions with service users and staff indicate that there are clear strategies for communication in the home. Staff said they are continually encouraged to access training and personal development activities. There are clear lines of accountability within the home and also via external management arrangements. Presentation Sisters Care Centre DS0000002072.V325580.R01.S.doc Version 5.2 Page 21 The Quality Assurance systems were examined and found to be satisfactory. New questionnaires had been developed and these were discussed with the administration manager. Questionnaires had been sent out to relatives and residents and this was to be undertaken on a six monthly basis. The results of these questionnaires had been analysed and actioned. Residents meetings were held on a regular basis and relatives were invited to attend. Residents are helped to take responsibility for managing their own money, where possible, although the majority of residents in the home have help from their families. Pocket money for some residents is kept by the home and records of these were seen. All receipts and signatures are recorded. Systems are in place for the maintenance of equipment, details of which were provided in the pre inspection information. Some of the safe working practices of the home were examined, this included; fire alarm test certificates, fire fighting equipment checks and certificate of inspection, fire training and weekly fire alarm tests. Other safety certificates and records were examined and all were found to be satisfactory. It was clear from the evidence seen that the home took reasonable measures to ensure the health, safety and welfare of residents and staff. The evidence included: records of accidents and incidents in the home; records of fire alarm tests, fire drills, maintenance of fire safety equipment; checks of hot water temperatures; measures taken to control the risk of Legionella; risk assessments of working practices; and the home’s policies and procedures regarding health and safety issues. Staff spoken with showed a good awareness of health and safety issues and how to minimise risks to residents and staff. The home has in place a health & safety consultation committee which meets to discuss and action any health & safety issues. Minutes of these meetings were seen. The majority of policies & procedures have been updated within the last 12 months. Each month a policy of the month is displayed in the staff room and staff sign to say this has been read and understood. The home had been working towards Investors in People Award and were being assessed for this in March 07. All outstanding requirements had been actioned and no new ones made at this inspection. Presentation Sisters Care Centre DS0000002072.V325580.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 4 4 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X 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 X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 4 Presentation Sisters Care Centre DS0000002072.V325580.R01.S.doc Version 5.2 Page 23 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 OP9 Good Practice Recommendations Medication Administration Records, (MARs) should be signed by the person administering the medication. Photographs of the resident on the MAR sheet could help reduce the possibility of mistakes. Consideration should be given to increasing the hours worked by the activities staff so that the activities programme offered can be expanded. All complaints should be recorded in the complaints book. Different ways of paging staff should be looked into, as the present system is quite intrusive for residents. The level of staff required should be continually monitored due to increasing needs of some of the nursing patients. 2. OP12 3 4 5 OP16 OP19 OP27 Presentation Sisters Care Centre DS0000002072.V325580.R01.S.doc Version 5.2 Page 24 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.V325580.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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