Inspection on 01/09/08 for St George`s Court Care Centre

This inspection was carried out on 1st September 2008.

CSCI found this care home to be providing an Good service.

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

St George`s Court Care Centre 14/02/07

St George`s Court Care Centre 10/04/06

St George`s Court Care Centre 25/10/05

St George`s Court Care Centre 27/01/05

St George`s Court Care Centre 22/06/04

St George`s Court Care Centre 06/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE St George`s Court Care Centre Russell Street Cambridge Cambridgeshire CB2 1HT Lead Inspector Alison Hilton Unannounced Inspection 1st September 2008 07:40 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 St George`s Court Care Centre DS0000015238.V371053.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. St George`s Court Care Centre DS0000015238.V371053.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St George`s Court Care Centre Address Russell Street Cambridge Cambridgeshire CB2 1HT 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) 01223 712135 01223 712138 St George`s Court Healthcare Ltd Manager post vacant Care Home 76 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (56) of places St George`s Court Care Centre DS0000015238.V371053.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users who require nursing care is 29 Date of last inspection 6th September 2007 Brief Description of the Service: St George’s Court Care Centre is a care home for up to seventy-six older people. The home is built on three floors, and each floor offers a home to a different resident group. The majority of residents on the top floor need nursing care: there is at least one registered nurse working on this floor at all times of the day and night. The middle floor is divided into two separate units: one offers care to twenty people with dementia; and one has twelve places for older people who need assistance because of physical frailty. There are six permanent places on the ground floor, and ten places which are used for interim care (people waiting for places elsewhere). Half of St George’s Court was built in 2005/6 as an extension to the original 1970s building, which was fully refurbished at the same time. Each of the four units has its own lounge and dining areas with a small kitchenette, a number of single bedrooms, and bathroom and toilet facilities. All of the new bedrooms have an ensuite shower room with toilet and washbasin. Some of the bedrooms in the original building have ensuite facilities, and the seventeen other bedrooms have a washbasin. There are two passenger lifts and staircases for access to the upper floors. On the ground floor there is a large kitchen where all the meals are prepared; a small rehabilitation kitchen; a laundry, which serves the whole home; and offices. There are staff facilities on each floor and a smoking area for residents and visitors on the ground floor. There is a very attractive central courtyard garden. St George’s Court is in a residential area close to the centre of the city of Cambridge. There are local shops, churches, pubs, restaurants, banks and a post office within a few minutes walk; the city centre is a short bus ride away; and the main-line station with direct links to London and the North is in walking distance. The majority of places at St George’s Court are ‘block-booked’ by Cambridgeshire Social Services. The current local authority fees (as at August 2008) are £368 for frail elderly; £454 for dementia care; and £550 for nursing. Fees for privately funded places are available on request. Copies of the CSCI’s inspection reports are available in the entrance foyer of the home. St George`s Court Care Centre DS0000015238.V371053.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. We, the Commission for Social Care Inspection (CSCI) carried out a key unannounced inspection of St Georges Court on Monday 1st September 2008 at 07:40 hrs using the Commission’s methodology described below. This report makes judgements about the service based on the evidence we have gathered. Staff (including night staff), people who live at the home, visitors and the manager were spoken to. An Annual Quality Assurance Assessment (AQAA) was completed and returned to the Commission prior to this inspection. This is an assessment completed by the manager of the home to show what is done well, how things have improved and plans for further improvement and development. Surveys were sent to care workers, relatives and people living in the home. Information they provided will be in the body of the report. A number of records were seen, together with two staff personnel files and three files of people living in the home. What the service does well: What has improved since the last inspection? Care plans now contain sufficient information for staff to be able to provide the level of care needed to meet people’s health and welfare needs. St George`s Court Care Centre DS0000015238.V371053.R01.S.doc Version 5.2 Page 6 An activities organiser has been appointed and she will undertake to provide more varied activities. The manager holds monthly meetings with people living in the home to discuss what they want to do and activities they wish to take part in. Staff have received training in keeping people living in the home safe from harm. Staff who work in the dementia unit have had training in dementia care and further in depth training is being provided over the coming months. Staff are involved in fire drills and this information is recorded. Staff are being provided with access to English Language courses for those who work in the care sector. The staff rota was accurate and showed sufficient staff are available on each floor to meet the needs of people currently living in the home. 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. St George`s Court Care Centre DS0000015238.V371053.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 St George`s Court Care Centre DS0000015238.V371053.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): 1,3,5,6 Quality in this outcome area is good. Information about people who want to move into the home is gathered so that they know their needs can be met. People are given information and encouraged to visit the home so that they can decide if they want to move in. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Information provided in the surveys completed by people living in the home was as follows. “I was told it was a nice home”. One person was placed through the hospital and did not ask for information as they were in an interim room. “I was discharged straight from hospital and this was the only place available with en suite toilet”. People spoken to during the inspection said they had had enough information to make a decision about moving to the home; whilst others had been placed in the interim beds by the local authority and had no choice about where they were sent. St George`s Court Care Centre DS0000015238.V371053.R01.S.doc Version 5.2 Page 9 Details in the AQAA showed that people who might want to live in the home were offered the opportunity to view it with their families prior to admission, in order to establish whether or not they liked it. A home brochure is being produced at the moment, with information and pictures of the home and there are plans to review the service user guide and add photographs to make the information easier to read and to show what the home is like. The pre admission assessment form has been looked at by St Georges Court Healthcare Ltd, and this has resulted in an improved document being used in the home. We looked at the files of three people living at St George’s Court and there were assessments from placing authorities, hospital discharge notes and the pre-admission assessment completed by staff at the home. Standard 6 looks at Intermediate Care. Intermediate care is a service offered by some homes to give short-term, intensive rehabilitation for people leaving hospital before returning to their own homes. This service is not offered at St. George’s Court; therefore standard 6 is not applicable. St George`s Court Care Centre DS0000015238.V371053.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): 7,8,9,10,11 Quality in this outcome area is good. Care plans contain good, detailed information to make sure that all aspects of each person’s needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Details provided in the AQAA showed that the manager conducts regular internal and external audits in order to identify any areas of concern or to give praise to an area that has done well. Care plan audits are carried out on a monthly basis along with health and safety, pressure sore and medication. This enables the manager to develop an overall picture of what type of care is received by those living in the home. Improvements will be made through inhouse line management and mentoring of staff, and also through continued professional development of the staff group. St George`s Court Care Centre DS0000015238.V371053.R01.S.doc Version 5.2 Page 11 We looked at three care plans and it was good to see information that helped people maintain their independence for example ‘remind X where the toilet is, but she can manage to get to and use the toilet’; and that ‘X needs prompting to get dressed and can manage that, but may need help with buttons and zips’. All care plans had been updated and where assessments were to be done weekly this had been actioned by staff. Risk assessments had also been updated and provided good information for staff to care for people in the home safely. There was information on the care plans that showed how people’s healthcare needs had been met with visits from a GP, District Nurse and podiatrist. There was also evidence that specialist help was sought when needed from the tissue viability nurse, dietician and psychiatric services. Pressure area care was seen for one person in the home and there was good detail in the care plan; for example where the nightdress must be changed immediately if soiled, and staff spoken to were aware of this. There were details that this person must be turned 2 hourly in the day and hourly at night. On checking the records this had not been done and on 31/8 turns were made at 00:20, 03:30, 06:40, 11:40, 14:00, 18:30 and 21:40. On the 1/9 (the day of inspection) the times were 00:25, 03:35, 06:10, 08:30 and 10:45. There were some entries when the person did not want to be turned, but if this were the case then each time it happened it must be recorded to ensure the wellbeing of the person. The manager said that there would be an immediate implementiaon of 2 hourly checks and staff would be spoken to to ensure this happened. She created a new recording format for staff the following day and forwarded a copy to the Commission. Food and fluid charts were checked for this person and on 31/8 she had 305mls of fluid. Entries showed that she had refused a drink and how much had been drunk at other times, however there were large time gaps when nothing is shown as being offered eg between 07:30 and 11:00, and 11:00 and 18:00. On 29/8 she had 720mls and on 30/8 540mls intake of fluid. On speaking to the lady she was unable to tell us what she had had to drink, but was not thirsty whilst we were there. Two people we spoke to said they did not want to have the responsibility of administering their own medication and were happy for the staff to do it. Another used to self administer his medication but was unable to do so now because of problems with his hands. We checked the Medication Administration Record (MAR) charts and they had been completed showing that staff were competent to administer them safely. There are specimens of each persons signature at the front of the MAR charts, which are updated 6 weekly to ensure signatures of those administreing medication are recognised. Controlled drugs are kept and the numbers are checked each night by the Registered Nurse, and the manager completes a drug audit each month. St George`s Court Care Centre DS0000015238.V371053.R01.S.doc Version 5.2 Page 12 People in the home said that staff were very nice and kind. They felt they were treated with respect and enjoyed the company of the staff on duty. The manager was aware of the different religious and cultural needs of people (see also daily life and social activities standards 12-15) and the files now include instructions of what to do after death. St George`s Court Care Centre DS0000015238.V371053.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. People are given some opportunities to lead the lifestyle they want to lead. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information from the surveys completed by people living in the home showed that “The vegetables are undercooked”, “I would like scrambled eggs on toast, steak and kidney pudding and cabbage.” “The entertainer who used to call and play keyboards does not come anymore and we have 2 guitar players/singers in about the last 4 months. The days are very boring.” One person said there were never activities they wanted to take part in. “Bingo is the only thing I like”, was the comment from another person. One person spoken to during the inspection said he had a computer and used it to link up with friends in other countries. Details provided in the AQAA showed that the manager is continuing with regular residents/relatives meetings to ask for people’s opinions as to whether St George`s Court Care Centre DS0000015238.V371053.R01.S.doc Version 5.2 Page 14 the service offered remains adequate to meet their needs and what could be improved. An activities organiser has been employed to continue with the activities offered at St Georges and enhance the quality of life for the residents’ but because of the slow criminal record check she has not been able to begin work. In discussion with the manager she said that she is looking for new entertainers to come to the home, and also looking for new venues to take residents. She has found a PAT dog (but it is still in training) and ‘animal therapy’ where they bring snakes and spiders for people to look at. The manager said that she hope to be able to link with other homes in the group to purchase a mini-bus between them and then have use of it on a rota system. Currently the home is using dial-a-ride to supply trips out for some people in the home. Some have family or friends who take them out for the day, as was the case during the inspection with one lady going to Clacton. The manager hopes to start up a charity and have fundraising for the people living in the home. She is also encouraging local schools and colleges to attend the home with activity ideas. A priest attends the home to conduct mass, and the manager wants to contact other denominations to ensure everyone who wants to has access to a service. It was noted by staff that in the unit for people with dementia, some people would look in the door (as if looking in a mirror). The Manager completed research before putting mirrors in the unit (as there are differing views on the suitability of their use) so the ladies could enjoy using them to brush their hair, put make up on and generally look in as they walk past, and the men to straighten their ties. The manager said behaviour was being monitored to ensure no-one became upset by them, but so far staff had reported a very positive outcome. The dining rooms were nicely set with tablecloths, cutlery and condiments. The meal on the day of inspection was cottage pie or broccoli and cauliflower cheese with vegetables, followed by apple crumble and custard or yoghurt. One person said the meals were good and they used fresh vegetables. It was evident during an observation of lunchtime that meal portions are very large and at least four people on one unit requested a smaller portion. It was discussed with the manager that large portions are off putting and may mean people do not eat anything as a result. She said she would discuss with staff and ensure the meals were suitably presented in smaller portions. It was nice to see that people had a choice of using a coverall at lunch if they wished. Most people said they had enjoyed the meal but one lady had not enjoyed her crumble. St George`s Court Care Centre DS0000015238.V371053.R01.S.doc Version 5.2 Page 15 We saw the minutes of meetings held on each floor involving people living in the home and staff. Some ideas for activities such as making bread, renting a video for a cinema night, audio tapes, visit the botanical gardens, Scotsdales and Hornsea garden centres, a fish and chip night, bingo with prizes were raised and the manager (with the mew activities organiser) is looking into it. There were also suggestions about meals and that more cooked breakfasts would be good, plain sponges (not fancy), porridge and more fresh vegetables could be made. Although there is a lot of information about what will happen it is not happening at the moment, which is why this section has been scored as adequate. St George`s Court Care Centre DS0000015238.V371053.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. Residents know their concerns will be addressed, and staff are adequately trained in protecting adults to be sure that residents are safe from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Safeguarding trainer was at the home to provide training on the day of inspection. She ran two sessions so that staff who had not had up to date training could attend. There are two staff who have been unable to attend this update but the manager was arranging a further date for them. There have been no complaints at the home since the last inspection. The Commission has not received any complaints about the service. There is information in the home to show anyone how to make a complaint. People spoken to in the home said they would speak to a member of staff or the manager if they were not happy with something. This was also confirmed in the surveys returned by people living in the home, for example “ I would speak to staff.” One person named the person they would speak to. One person did not know who to speak to if they wanted to complain, but would speak to a named person if they were not happy. Most ticked the box to say they knew how to complain about the service. St George`s Court Care Centre DS0000015238.V371053.R01.S.doc Version 5.2 Page 17 Details in the AQAA showed that any Protection of Vulnerable Adults issues have been dealt with according to policy, and issues rectified. St George`s Court Care Centre DS0000015238.V371053.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): 19,23,24,25,26 Quality in this outcome area is good. St George’s Court offers those who live there a clean, pleasantly decorated and comfortable place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Comments received in the surveys included: - “I like the home and I like my own room.” “Bins are not emptied every day and more hoovering is needed.” One relative showed us that the lounge near the entrance had a layer of dust on the fire, tables and radio. This was shown to the manager who said she would implement a cleaning protocol with the ancillary staff. She intended to do this but has only been in post three months and had already undertaken many positive changes in the care and welfare of people living in the home. St George`s Court Care Centre DS0000015238.V371053.R01.S.doc Version 5.2 Page 19 Details provided in the AQAA showed the manager had received positive feedback when showing visitors around the home. There have also been written compliments and donations given for our comfort funds. The manager said that the standard of the home environment was being improved by using the homes action plans and meetings with relatives and residents to get a clearer understanding of the environmental requirments. The home has a full time maintenance man who is consistently striving to improve and maintain the home environment. Bedrooms seen during the inspection appeared light and clean. The rooms had personal touches such as photographs and pictures and people were very happy with their rooms. One downstairs toilet needs some maintenance around the sink and heater cover that look unsightly. St George`s Court Care Centre DS0000015238.V371053.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. Resident’s benefit from a staff team that is well trained, well supervised, and committed to improving the quality of the care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two staff files were seen and they contained the necessary information. There was evidence of an induction for both staff members but as yet neither have received supervision as they have not been working in the home that long, although it is arranged for later in the month. Surveys returned by members of staff showed they received checks before starting work and were given an induction. Regular meetings and handovers were held in the home. Some felt ‘more staff were needed over holiday periods to cover A/L’. Under the heading ‘What the service does well’ examples from staff included: “Look after the residents. Good relations with relations”. “Meeting service users distinctive needs”. “Well supported by the RGN’s.” “Provided with an induction led by unit managers.” Comments received in the surveys from people who live in St George’s Court included: - “The staff are good and helpful.” “Staff are very helpful, friendly St George`s Court Care Centre DS0000015238.V371053.R01.S.doc Version 5.2 Page 21 and patient.” “There are usually staff about, if needed”. Under the question ‘Do staff listen and act on what you say?’ the following comments were made: “only when they understand English.” “Good support of staff. The manager listens to staff, residents and relatives. Action plans to deal with issues raised.” “St Georges Court has come a long way.” Details in the AQAA showed that the manager had a staff training matrix and individual staff training files. There is a tailored appraisal format and supervision structure, which is reviewed on a 6-9 weekly basis; this also includes a development plan, which addresses staff performance. The manager is providing an in-depth induction for all new staff and trying to improve on this by giving more structure to the induction programme and basing it on the individual’s needs. For example some of the staff do not have English as their first language so the manager is trying to implement English lessons for them. Some of those living in the home said they had problems understanding some staff, which can lead to misunderstandings, although they said the staff tried very hard and . New staff are getting an induction including 3 supernumerary shifts, and mandatory training. The manager said that ancillary staff will be completing NVQ Level 2 in cleaning and support services; kitchen staff will be completing NVQ Level 2 in food preparation; administration staff will be completing NVQ Level 2 in administration. Seven or eight care staff will be completing NVQ Level 3 in health and social care. Some nurses said they wanted to complete a phlebotomy course and the manager is arranging this. The manager and senior staff have also undertaken observational audits and the result has been input on working on effective personal care. Staff rotas showed that on the ground floor there are three staff 8am-2pm and three 2pm-10pm. On the middle floor there are six staff am and six pm. On the top floor there is always a registered nurse on duty plus five care staff am and four pm. There are seven staff on duty at night including one registered nurse. These numbers do not include the manager. There has been an increase of staff on the middle floor to ensure people are well cared for and their needs can be met. St George`s Court Care Centre DS0000015238.V371053.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): 31,32,33,35,36,38 Quality in this outcome area is good. Residents can be confident that this home is managed well so that they have good quality of life and are kept safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff and people living in the home are quietly optimistic about the changes made by the new manager. One of the main comments during the inspection was that the home had had three managers in the last year and people hoped this one would stay. They liked her manner and openess and that she was ‘hands on’. People living in the home were concerned that they would get used to a new manager and then she would leave. One person St George`s Court Care Centre DS0000015238.V371053.R01.S.doc Version 5.2 Page 23 could not remember the new manager’s name. The Manager of the home (who is not yet registered), is trained as a Registered Mental Nurse and has a Diploma in Higher Education. She has been working at St. George’s Court since 09.06.08. The manager has put training, supervision and appraisal systems in place to ensure staff obtain the support and education that will enable them to undertake their job role as effectiently as possible, and that any concerns can be sorted out. The requirments of the Data Protection Act with regards to access and storage of people’s records are followed at all times. All records are completed in line with requirments of company policyand statutory inspecting bodies. The ethos of the home is open and transparent with the views of both staff and residents listened to and valued. Details in the AQAA showed there is an efficient system to ensure effective safe keeping and management of residents monies including record keeping. People wishing to take responsibility for their own money/valuables have a locked drawer available in their room. Staff have easy access to all policies and procedures, which are discussed in staff meetings. Details in the AQAA showed policies and procedures had been reviewed in 2007 or 2008. Maintenance files are kept up to date. Updated policies and procedures are in place for safe working practices i.e. Record of food, fridge temps on a daily basis. Regular audits take place, medication, care plan, health and saftey risk assessment and action plans review weekly. Quality assuarance survey results, Health and Saftey audits, maintenance logs and business plan are all being completed in order to monitor effective care provided. Information in the AQAA showed that a Health and Safety Rep has been identified for the home and they carry out monthly audits. All areas of the home are being audited weekly/monthly as required i.e. Care Plans/Medication/Pressure Sores. The Home Action plan is updated monthly or St George`s Court Care Centre DS0000015238.V371053.R01.S.doc Version 5.2 Page 24 sooner identifying all outstanding areas from the audits with identified timeframes to complete. St George`s Court Care Centre DS0000015238.V371053.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 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 3 3 X 3 3 X 3 St George`s Court Care Centre DS0000015238.V371053.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 OP12 Good Practice Recommendations The programme of possible activities should be put into practice as soon as possible. St George`s Court Care Centre DS0000015238.V371053.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 St George`s Court Care Centre DS0000015238.V371053.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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