Inspection on 14/11/06 for Queen Mary House

This inspection was carried out on 14th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Queen Mary House 29/11/05

Queen Mary House 02/05/05

Queen Mary House 02/09/04

Queen Mary House 27/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Queen Mary House Manor Park Road Chislehurst Kent BR7 5PY Lead Inspector Sue Meaker Key Unannounced Inspection 10.00 14th November 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 Queen Mary House DS0000038956.V308943.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. Queen Mary House DS0000038956.V308943.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queen Mary House Address Manor Park Road Chislehurst Kent BR7 5PY Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8467 3112 School Mistresses and Governesses Benevolent Institution Susan Perry Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Queen Mary House DS0000038956.V308943.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th November 2005 Brief Description of the Service: Queen Mary House is a large, detached three storey, purpose built home. The home is situated in a quiet residential area in Chislehurst in the London Borough of Bromley. The home is close to open woodland and Chislehurst common, and within walking distance of local shops and public transport. The home is administered by the Schoolmistresses and Governesses Benevolent Institution, a charity founded in 1843 and incorporated by Royal Charter, the home provides spacious accommodation in pleasant surroundings, for retired ladies from these and comparable professions. The home is surrounded by well maintained gardens which are easily accessible to the service users. Bedrooms are on two floors accessed by a passenger lift, benefiting from central heating, the temperature of which can be individually controlled by the service users. There are hand and grab rails on the stairs, in passageways, toilets, showers and bathrooms. Specialised bathing and toilet equipment and moving aids are readily available; all toilets, showers, bathrooms and bedrooms can be accessed from the outside in case of an emergency. There is easy access to a telephone and the majority of service users have their own telephone in their rooms. There is an emergency call system in all areas of the home used by the service users; and members of staff are on hand at all times to assist the service users as required. Queen Mary House DS0000038956.V308943.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a statutory unannounced key inspection that took place over five hours, records were inspected, a tour of the premises was undertaken, lunch was observed, administration of medication was observed at lunchtime. A number of residents and members of staff were spoken to and eight questionnaires were received from residents that included comments from their relatives. A pre-inspection questionnaire had been completed by the home manager and included copies of the menu, rotas, training programme, list of reviewed and updated operating policies and procedures and comprehensive lists of residents and staff. What the service does well: This home provides a good quality service to its residents; providing a safe and homely environment, the home is spacious, comfortable, well decorated and furnished to a high standard creating a home from home atmosphere clearly appreciated by the residents and relatives. The home benefits from effective, efficient and caring management team and a truly committed staff team; who receive good training enabling them to have the skills and competency to meet the assessed personal, health and social care needs of the residents in their care. The home has a good activities programme incorporating social events, external entertainment and outings provided by an activities co-ordinator with enthusiastic support and encouragement from staff, residents and their relatives. These are some of the comments made by residents and their relatives:• I like it very much here, the manager and her staff are helpful and caring to my needs. • My stepson enquired of seven homes before I chose this one, this is a perfect home long may I stay. • Meals excellent, access to a spacious and lovely garden, regular visiting hairdresser, regular supervised bathing, availability of wheelchairs when needed. • We regard the standard of care and support at the home as outstanding it maintains an extremely happy family atmosphere offering residents an individualised care package with sensitivity and a huge commitment. • Mother is unable to communicate but the staff try very hard to understand her needs. • The management and staff at the home are approachable. Queen Mary House DS0000038956.V308943.R01.S.doc Version 5.2 Page 6 • If I need care and support again I hope I can come to this home the staff are friendly and helpful. Queen Mary House provides a high standard of care to its residents in a congenial atmosphere. The residents appear to happy and content in their environment and the staff also are part of creating this atmosphere within the home. The home is to be commended on its high standard of service provision achieved by competent management and a caring and committed staff team. 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 Queen Mary House DS0000038956.V308943.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. Queen Mary House DS0000038956.V308943.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 Queen Mary House DS0000038956.V308943.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Prospective residents are able to access information about the home enabling them to make an informed decision as to whether the home can met their health, personal and social care needs. Residents are assessed, prior to admission by the home manager, and receive contracts stating the terms and conditions of their residency. EVIDENCE: Residents and their relatives are given detailed information relating to the home and the services offered, in the form of a brochure detailing the homes’ Statement of Purpose that includes the aims and objectives of the home, the services provided, the complaints procedure and the relevant qualifications and experience of the provider, manager and staff. This was evidenced from comments made on the questionnaire given to residents, the family of one resident stated that they were given detailed information about the homes’ Queen Mary House DS0000038956.V308943.R01.S.doc Version 5.2 Page 10 ethos, the facilities available, accommodation, food and medical care and that they visited and were made welcome in the home prior to their mothers’ admission. Another resident said that her daughter was shown the accommodation and given all relevant information which was highly satisfactory. Questionnaires received and residents spoken to confirmed that they had received a contract from the organisation detailing their terms and conditions of residency and that the contract was clear and easy to understand, a copy of the contract is given to the resident and one is kept on their personal file. On checking a number of personal files evidence that an assessment of health, personal and social care needs had been undertaken by a qualified member of staff was seen. The pre-admission assessment although covering the basic requirements of the standard does need to be expanded so that the care plan can be individualised more to the residents specific needs, it is understood that this documentation is to be reviewed and revised. It was evident from looking at the assessment documentation that the home was able to meet the needs of the resident; where specific medical needs were identified the relevant health professionals had been contacted to provide an individual service such as the tissue viability nurse, the district nurse and physiotherapist. It was also evident that the home could provide the services of a podiatrist, dentist and optician on request. Queen Mary House DS0000038956.V308943.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Care plans are good giving relevant information on how staff can meet the assessed personal, health and social care needs of the individual whilst respecting their personal choices and their right to independence, privacy and dignity. EVIDENCE: A number of care plans were looked at during the inspection it was noted that the information was pertinent to the care needs of the individual, the care plan covered the activities of daily living. The care plan is formulated from the preadmission assessment and reviewed and amended on a regular basis; the home manager is currently reviewing the care plan and risk assessment documentation. From speaking to the residents and looking at the questionnaires received it was evident that the staff understood and had the skills to care for them and that the residents and their relatives were confident that their health, personal and social care needs were met. One of the residents said that she liked it very much in the home and that the home Queen Mary House DS0000038956.V308943.R01.S.doc Version 5.2 Page 12 manager and her staff were always helpful and caring to her needs. Another resident ‘s family stated that they have been impressed by the care and support their mother has received, nothing was too much trouble for the staff who were well informed of their mothers needs that were met with sensitivity, good humour and patience. Another relative said that her mother was unable to communicate but the staff tried very hard to understand her needs. Residents and relatives were also appreciative of the additional medical services that the home was able to access, this was usually done through the GP, and this was evidenced from the recording, by the staff, on the daily evaluation sheets in the individual care plans. The lunchtime medication round was observed and the documentation was checked and found to comply with the standard. Medication is dispensed from the blister pack and recorded on the individual medication administration record. Photographs should be individualised to the MARS sheet for each resident, not all together, and the medication file should be sectioned for each resident. Medication is stored safely and securely; only trained staff administer the medication and staff have recently received training in the Safe Administration of Medication as documented in the staff files. It was evident from observing the interaction between the residents and staff that they are treated respectfully and are assisted in a sensitive manner, the staff appeared to have a good rapport with them and the atmosphere in the home reflected this; residents said that the staff were helpful and caring, approachable, friendly, available and committed to meeting the care needs of their residents. Queen Mary House DS0000038956.V308943.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are supported and encouraged to maintain their links with the community and to choose to participate in activities organised by the home, with input from residents and relatives, thereby enabling them to maintain their hobbies and interests. Residents enjoy well-prepared, healthy and nutritious in pleasing surroundings at a time convenient to them. EVIDENCE: The management and staff of the home offer a variety of activities, entertainment and outings to their residents on a regular basis: residents had recently enjoyed outings to local garden centres and the Pump House Museum. The home provides regular musical entertainment by performers coming into the home, recently the residents enjoyed storytelling from Athene and Arachne relating to greek and roman legends. There had been flower arranging sessions in which the residents could participate. The home manager had accessed the Reminiscence and Communication Service who have provided information relating to appropriate activities for the residents. The home has a regular activities co-ordinator who is currently arranging the entertainment for Queen Mary House DS0000038956.V308943.R01.S.doc Version 5.2 Page 14 the Christmas period and this is to include a 1910 – 1950 Song and Dance Review to be put on by the homes’ staff; there will also be a church and carol service with the army cadet band and the Chislehurst Beavers and a Christmas party will also be arranged for the residents. The activities co-ordinator arranges many activities throughout the year including gentle exercise, quizzes, board games, arts and crafts and indoor bowling. One resident said that the events organised by the home are of quality as opposed to quantity and another residents’ family said that there were a number of activities their mother participated in including scrabble and also several events including the annual trustees party and the Christmas panto. Residents confirmed that their relatives and friends are encouraged to visit the home at times suited to them and that they are invited to social events and asked if they would like to participate in the organising activities and social events. The home encourages local churches, local schools and volunteer groups to visit the home therefore maintaining contact with the local community. Lunch was observed, the atmosphere in the dining room was calm and dignified, residents sat at tables for four people that were set with tablecloths, serviettes and condiments. Residents had a choice of two main meals, desserts and beverages, alternative choices were provided for vegetarians and special diets and for residents who did not like the main meals offered. The residents in the main dining room were served by staff members and were able to eat unaided. Some residents preferred to have their meals in their rooms, they were assisted by staff in a sensitive and courteous manner. Residents spoken to said how much they enjoyed the meals and also the social time with other residents in the dining room. The kitchen was given a gold clean food award in May 2006, by the London Borough of Bromley’s environmental health officer. Queen Mary House DS0000038956.V308943.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The homes’ policies, procedures and training relating to the Protection of Vulnerable Adults and complaints ensure that residents feel safe and protected at all times. EVIDENCE: The home has a robust complaints policy and procedure that is readily available in the homes’ Statement of Purpose and Service Users Guide; the complaints procedure is also displayed in the foyer of the home. Residents and their relatives confirmed that they knew how to make a complaint if the need arose. They stated that the management and staff of the how were approachable, friendly and helpful and this gave them the confidence to raise any concerns that they might have concerning their care. Residents said that the home manager dealt quickly and effectively with any concerns they raised. From the training files and from speaking to staff it was evident they understood the importance of the Protection of Vulnerable Adults, that they were aware of all forms of abuse and that they knew who to report allegations of abuse to and that they were aware of the homes’ “whistle-blowing” policy and procedure. The home is governed by the guidelines produced by the London Borough of Bromley relating to the Protection of Vulnerable Adults; management and staff had received training from the local authority about this issue and in house training had also been provided through training videos and workbooks. The home has a copy of the Bromley Guidelines and the Department of Health guidance “No Secrets”. The home manager is aware of the legislation relating to the POVA register. Queen Mary House DS0000038956.V308943.R01.S.doc Version 5.2 Page 16 The questionnaires completed by residents in conjunction with their relatives evidenced that they are very satisfied with the care services provided by the home and that they feel very safe and supported by the home that has their protection and safety as a priority. Staff understood the importance of promoting the individuals’ rights, which is why the home has, in place, systems that ensure the resident’s rights are respected. Queen Mary House DS0000038956.V308943.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home provides a safe, comfortable, clean and well-maintained environment for their residents so they are able to enjoy their preferred lifestyle. EVIDENCE: The home is decorated and furnished to a high standard providing residents with pleasant, homely surroundings in which to live comfortably. The home was clean, tidy and free from any odours and it was evident that the team of domestic staff maintain the home to a high standard. All residents have single rooms, some of which have en-suite facilities, decorated and furnished to a high standard. It was noted, during a tour of the home, that all bedrooms were personalised reflecting the residents’ hobbies and interests; some of the residents also had their own pieces of furniture, ornaments, pictures and photograghs Queen Mary House DS0000038956.V308943.R01.S.doc Version 5.2 Page 18 The communal areas of the home, the lounges, dining rooms, conservatory and the library are well decorated and comfortably furnished retaining a home from home feel for the residents. One residents’ family said that our mother’s room is clean, the bedclothes and towels are always spotless as are her clothes; and that the home maintains an extremely happy family atmosphere. Another resident said that the accommodation was highly satisfactory and another said” this is a perfect home, long may I stay”. The home has an extensive garden, accessible to all residents, the garden is well used in the spring and summer months when at its best, very attractive and well- maintained with plenty of seating areas one of the residents said that the garden was spacious and lovely. The home has an ongoing programme of refurbishment and re-decoration and a committed maintenance person to carry out the work. The home ensures the health and safety of the residents, ramps are provided for wheelchair users and the corridors, communal areas and the gardens have handrails. The home has a well-maintained passenger lift giving residents access to all areas of the home. Queen Mary House DS0000038956.V308943.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The management of the home ensures that all staff are trained in order to have the skills and competency necessary to meet the personal, health and social care needs of the residents in their care; this outcome is achieved by implementing thorough recruitment, selection and training policies and procedures. EVIDENCE: Staffing levels have been increased recently in order to meet the increased dependency of the residents. Rotas seen showed that the number and skill mix of staff are appropriate to the assessed personal, health and social care needs of the residents in the home. The home has robust recruitment and selection procedures; each member of staff now has their own personnel file containing the information specified in Schedule 2 of the National Minimum Standards; therefore complying with regulation 19 of the Care Standards 2000. The home has a comprehensive training programme in place and a designated budget to maintain a high level of training. The home is a member of the Bromley Training Consortium and is now able to access training courses relating to moving and handling, risk assessment, loss and bereavement, dementia introduction, dementia intermediate, report writing, basic assessment and safe administration of medication. The home manager has Queen Mary House DS0000038956.V308943.R01.S.doc Version 5.2 Page 20 also accessed external training in infection control (from NHS), customer care (working with relatives and understanding older people),equality and diversity and depression in older people. Induction training for new employees complies with Skill Council by way of BVS – common induction standards with a workbook to complete within six weeks prior to undertaking NVQ 2.Currently 46 of care staff have achieved NVQ 2 and 2 staff commenced the training in September 2006; five members of staff hold a valid first aid certificate. It was evident from the training files and from speaking to staff on duty that they had regular updates for their mandatory training in moving and handling, health and safety, fire and food hygiene. Queen Mary House DS0000038956.V308943.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has effective and efficient management and administration system in place to ensure the best interests and health and safety of the residents and stall; management make sure that the administration systems ensure the home is financially viable. EVIDENCE: The home has a competent and experienced manager who is supported by a committed staff team. The manger understands the philosophy of the home and is able to meet its aims and objectives as set out in the Statement of Purpose. From questionnaires received and from speaking to residents it was evident that they felt that the management and staff at the home were approachable, friendly, helpful, willing to listen, compassionate and sensitive to Queen Mary House DS0000038956.V308943.R01.S.doc Version 5.2 Page 22 individual needs. They also said that any concerns they raised were dealt with in a sensitive and compassionate manner and resolved quickly with the minimum amount of fuss and that there were always members of management around and accessible. The home has a ladies committee who visit the home on behalf of the Schoolmistresses and Governesses Benevolent Institution and this committee produces an annual quality of life questionnaire, The residents and their relatives are asked to comment on the provision of care, the accommodation and the meals, their anonymity being preserved. Issues raised by the residents were addressed and resolved by the management of the home and the home maintained records appertaining to these meetings held with staff and residents and relatives. The Home has a supervision and appraisal system in place and this is now fully implemented each member of staff has their own record of supervision and a personal development plan identifying training needs. The homes’ business plan was seen and it was evident from this document that the home is in good financial shape and is able to meet all current financial commitments. The home has robust policies and procedures in place relating to health and safety of residents and staff, the pre-inspection questionnaire showed that regular safety checks were undertaken and recorded in accordance with current health and safety legislation. Queen Mary House DS0000038956.V308943.R01.S.doc Version 5.2 Page 23 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 3 3 3 3 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 3 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 Queen Mary House DS0000038956.V308943.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. 2. Refer to Standard OP1 OP36 Good Practice Recommendations The home to provide the CSCI with the up to date brochure, when completed. The Registered Manager should ensure that all staff members receive documented supervision on a regular basis. The Registered Manager should ensure that the preadmission assessment documentation is reviewed and send a copy to the CSCI. The Registered Manager should ensure that the care plan documentation is reviewed and send a copy to the CSCI The Registered Manager should ensure that all the residents MARS sheets are sectioned with and individual photo of the resident attached to the MARS sheet. 3 4 5 OP3 OP7 OP9 Queen Mary House DS0000038956.V308943.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Queen Mary House DS0000038956.V308943.R01.S.doc Version 5.2 Page 26 - 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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