Inspection on 14/08/09 for St George's Home

This inspection was carried out on 14th August 2009.

CQC 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 Home 18/08/08

St George's Home 03/05/07

St George's Home 25/04/06

St George's Home 09/01/06

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE St George`s Home 116 Marshall Lake Road Shirley Solihull West Midlands B90 4PW Lead Inspector Lesley Beadsworth Key Unannounced Inspection 14th August 2009 12:00 DS0000064009.V377844.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. St George`s Home DS0000064009.V377844.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address St George`s Home DS0000064009.V377844.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St George`s Home Address 116 Marshall Lake Road Shirley Solihull West Midlands B90 4PW 0121 745 4955 0121 745 4955 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) St George’s Care Limited Mrs Magda Gleeson Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places St George`s Home DS0000064009.V377844.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP) 29 The maximum number of service users who can be accommodated is: 29 18th August 2008 Date of last inspection Brief Description of the Service: St Georges is a purpose built, two-storey residential home providing care for up to 29 older people. The home is close to local amenities, is on a local bus route on the main route through to Solihull and Birmingham. There are 23 single bedrooms and 3 double. Television and telephone points are available in all bedrooms. The home has open plan lounge areas and dining area. A quiet area is located on the first floor, with a balcony/roof garden area. There is a shaft lift for access to the first floor, providing wheelchair access to all parts of the home. Two of the bathrooms provide assisted bathing facilities. The rear garden is lawned, with some shrubs. Ample parking facilities are available behind security gates to the front of the property. The manager should be consulted regarding the fees for living at St. Georges. The Service User Guide states that fees do not include the cost of private services such as chiropody, dentistry, optician, hairdressing, personal toiletries, newspapers, dry cleaning, clothing or other personal effects. St George`s Home DS0000064009.V377844.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. The inspection included a visit to St Georges. As part of the inspection process the registered manager of the home completed and returned an Annual Quality Assurance Assessment (AQAA), which is a self assessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service. Surveys were sent to service users and three were completed and returned to us. Information contained within the AQAA, in surveys, from previous reports and any other information received about the home has been used in assessing actions taken by the home to meet the care standards. Three residents were case tracked. This involves establishing an individual’s experience of living in the care home by meeting or observing them, talking to their families, where possible, about their experiences, looking at residents’ care files and focusing on outcomes. Additional care records were viewed where issues relating to a resident’s care needed to be confirmed. Other records examined during this inspection included, care files, staff recruitment, training, social activities, staff duty rotas, health and safety and medication records. The inspection process also consisted of a review of some policies and procedures, discussions with the manager, staff, visitors and residents. The inspection visit took place between 12md and 8:30pm. What the service does well: All care files looked at included a pre-admission assessment that gave sufficient detail to enable the home to be able to make a decision about whether they could meet the person’s needs. Care plans reflected the person’s needs and gave the information staff required to meet those needs. They are reviewed monthly and are signed by the resident to show their involvement. A summary of the person’s life history and their daily routine were also included in their care file, which would be particularly informative for new and temporary staff to enable them to meet the needs of the residents. Evidence that residents’ ongoing health needs are met was seen in their records and included visits to or by GP, Opticians, occupational therapist, chiropodists, district nurse and out patients. The representative of a resident St George`s Home DS0000064009.V377844.R01.S.doc Version 5.2 Page 6 said in a survey they thought that one of the home’s outstanding features was its fast response to illness. Appropriate risk assessments were in place for falls, nutrition, moving and handling and pressure sores. There were also individual risk assessments as appropriate. These would minimise any risks in these areas. Residents are cared for in a respectful manner. The home provides a stimulating activity programme enabling residents to be occupied if they wish. Visitors are made welcome and their needs were considered. Residents and visitors can be confident that their complaints and concerns will be listened to and acted upon. Staff have undertaken training related to safeguarding adults in order to give them the knowledge and skills they need to be able to identify, and to safeguard residents from, abuse. St Georges offers the people living at the home comfortable surroundings that are clean, safe and well maintained. There are sufficient staff to meet the needs of the people living at the home. The importance of training is recognised. The home has achieved 83 of the care staff to have National Vocational Qualification Level 2 or 3 in Care, thereby exceeding the required 50 . Other mandatory training on health and safety issues has been provided. Staff recruitment safeguards the residents from the employment of unsuitable people. Residents’ whose money is held by the home have their financial interests protected. The home monitors and audits the services and practices to ensure that all services operate in the best interests of residents. Health and safety practices, training and policies and procedures protect residents and staff living and working in the home. What has improved since the last inspection? The Statement of Purpose and Service User Guide have been updated to give accurate information to the people choosing a care home. St George`s Home DS0000064009.V377844.R01.S.doc Version 5.2 Page 7 Improvements have been made in the appearance of the home with the provision of new light fittings and ceiling tiles in communal areas and new carpets in some bedrooms, new furniture in the porch making the entrance more welcoming and new garden furniture. The provision of new appropriate and secure medication storage, which includes the provision of a new medication trolley, cupboards and a medication fridge has improved the security and stability of the medicines. The medication system now safeguards the health and wellbeing of the people living at the home. Industrial laundry equipment that has the correct programmes has been installed. The laundry area is cleaner and tidier than previously. Infection control systems now in place, including improvements in shared rooms, assist in preventing cross infection. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. St George`s Home DS0000064009.V377844.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 St George`s Home DS0000064009.V377844.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information required to make a decision about choice of home is not available when needed. Preadmission assessments are carried out to assess if the needs of prospective residents can be met. EVIDENCE: The AQAA states that the Statement of Purpose and Service User Guide have been updated to correct the discrepancies identified at the previous inspection. In the surveys returned people said that they received enough information to help them decide if this home was the right place for them before they moved in and that they had received a copy of the home’s terms and conditions. Three care files were looked at as part of the case tracking process. Each had a pre-admission assessment that had been carried out in order to assess if the St George`s Home DS0000064009.V377844.R01.S.doc Version 5.3 Page 10 home could meet the person’s needs prior to offering them a place at the home. All the appropriate headings were included in the assessment and all medical conditions and needs were identified. There was sufficient detail to decide if the home could meet the person’s needs or not. These pre-admission assessments included a life history of the person and the name they preferred to be known by. Any special resources such as the need for pressure relieving equipment or a hoist for safely transferring a person from one place to another were recorded and any special needs, such as a person having difficulty in swallowing, were considered. Further assessment is carried out following admission. St George`s Home DS0000064009.V377844.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are care plans that instruct staff on the care required by people living at the home. Residents have access to health care professionals and are cared for in a respectful manner. The medication process safeguards residents’ health and welfare. EVIDENCE: The care files of three people were looked as part of the case tracking process. A document had been signed by each resident to show that they been involved in devising them. There was a care plan for all identified needs in each of them, which had been reviewed, and revised, monthly to ensure that they were up to date. The care plans also included a record of the resident’s choice St George`s Home DS0000064009.V377844.R01.S.doc Version 5.3 Page 12 of gender of the person who supported them in their personal care. All residents looked well groomed and were appropriately dressed. Medical history was recorded and care plans reflected this in the care files looked at. Care files also included the life history of the person and a brief summary of their daily routine, which would be especially helpful for new or temporary staff to meet the needs of the residents. A care file of a very recently admitted person of ethnic minority origin showed that their cultural needs had not been assessed or care planned. Discussion with the manager indicated that the family would be asked to assist with this and a revised care plan covering this person’s needs was forwarded to us within two days of our visit. This was detailed and would ensure that staff had the information they required to support the person appropriately. Daily records are completed by staff three times during a 24 hour period using a pre printed format that include headings for well-being, diet, fluids, visitors, continence, activities and concerns. There is a separate record for visits by health care professionals. Residents on going health care needs were being met with evidence of visits to or visits by the GP, District Nurse, occupational therapist, continence nurse, optician and chiropodist being identified in the care files looked at. On behalf of a resident their representative said in a survey, “One outstanding feature of St Georges is its very quick response to the first sign of illness.” and went on to say that during the years their relative had been at the home their “life had been saved on possibly a dozen occasions.” Another resident commented in reply to “What does the home do well?” said, “Look after me.” Records of falls, pressure areas, weight, bathing and nail checks, nutrition and nutritional screening were in place within the files looked at. Completed risk assessments for tissue viability in relation to the development of pressure sores (a break in the skin due to pressure, which reduces the blood supply to the area) were in place. The manager told us that none of the current residents had a pressure sore. Risk assessments were also in place for moving and handling (transferring a person from one place to another) including any need for, and type of, moving equipment. Individual risks were also assessed. All risk assessments seen had been reviewed at six weekly intervals in order to revise them if circumstances had changed. These would help to minimise risk in these areas as any required action was included in care plans. The medication system was inspected. The pharmacist supplies most of the medicines in a (monitored dosage system) where each medicine is dispensed in a blister pack from which to administer on a daily basis. St George`s Home DS0000064009.V377844.R01.S.doc Version 5.3 Page 13 The contents of the controlled drug cabinet were audited against the controlled drug register and the quantities were correct. A controlled drug cupboard that complied with regulations had been provided since the previous inspection enabling controlled drugs to be stored safely. Storage of other medication was also in good order. Current medicines are stored in, and administered from, a new lockable trolley and any stock medicines stored in a suitable lockable cupboard. A new lockable medical fridge has also been provided, the temperature of which had been recorded on a daily basis to ensure that any contents are stored at the correct temperature. The temperature of the room where medicines are stored was also monitored to ensure that it remained below 25ºC in order to maintain the stability of the medication. An audit was carried out on a random selection of the medication dispensed in their original packets and all were correct, tallying with the Medication Administration Records (MARS). All MARS had been appropriately completed and recorded with no missing signatures and no incorrect codes used. Only staff who have undertaken accredited medication training are responsible for medication. The AQAA tells us that their competence is assessed regularly and that six members of staff are working towards the Safe Handling of Medicines Distance Learning training at the local technical college. Observations and discussion with staff and visitors showed that residents are cared for in a respectful manner. The residents’ preferred names are recorded on their care file and heard to be used by staff. St George`s Home DS0000064009.V377844.R01.S.doc Version 5.3 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents were occupied and stimulated. Visitors were made welcome and their needs considered. Residents had choices and control over their daily lives and enjoyed the nutritious and varied meals provided. EVIDENCE: The home has an activity programme, displayed on the notice board, which is illustrated to assist those people with limited understanding or visual impairment. It includes sessions of cards, bingo, sing-along, gentle exercise, garden, trips to the local shops and garden centre, a sherry evening and ‘Ladies Hour’ (manicure and make-up). There were two activities planned each day at 2pm to 3pm and 3pm to 4pm or 7pm to 8pm. Residents’ care plans included their interests and social relationships. St George`s Home DS0000064009.V377844.R01.S.doc Version 5.3 Page 15 A comment made in one survey in response to the question, “What could the home do better”, was “If staff numbers permitted it would be beneficial to residents to have more outdoor pursuits.” Visitors were seen to be made welcome and offered a drink on arrival, which was confirmed by those spoken with. The AQAA tells us that “Relatives and friends are encouraged to be involved in the service users care plan and to keep regular contact.” Observations made and discussion with residents showed that people living and staying at the home have the opportunity to make choices in their daily lives, such as when to get up and go to bed, what to eat and where to spend their time. The menu is displayed in the dining room but could be in bigger print to ensure that most people can see it. Meals are taken in the improved dining area and over two sittings. There was no evidence of residents being hurried to finish their meal. Tables each had an artificial flower arrangement that staff told us had been done by residents in one of their flower arranging sessions. We joined the residents for a lunch of fish, chips and peas with alternatives of egg with the chips or faggots or sausages and mashed potatoes. There was also a dessert selection to choose from. To make sure that a person had the lunch they preferred the cook came into the dining room to ask what they would like with the Bakewell tart as she was aware the person did not like custard. The mealtime was A cook now works at teatime to avoid the need for care staff to be spending time away from residents in order to carry out catering tasks. The arrangements for main meals continue where the food is reheated under safe conditions after being cooked the day before. The manager and home owner were unable to explain any benefit in this arrangement but this has been the routine for some years, although the manager told us that Environmental Health had approved it. The surveys completed for us showed that these people “Always” enjoyed the meals at the home and this was further confirmed by the people spoken with who said that they also enjoyed the meals. The kitchen was visited and was clean and in good order. St George`s Home DS0000064009.V377844.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints are addressed appropriately and residents and visitors can be confident that their concerns will be listened to and acted upon. The home has policies, procedures and training to safeguard residents from abuse. EVIDENCE: A copy of the complaints procedure was displayed in the reception area. People spoken with said that they knew who to talk to if they had any concerns and the people who returned surveys to us answered “Yes” to the questions, “Is there someone you can speak to informally if you are not happy?” and “Do you know how to make a formal complaint?” Comments made by a residents or their representative included, “I had a small problem regarding various missing items belonging to my (relative) which I duly reported to the Home Manager. This was thoroughly investigated and resolved to my complete satisfaction.” “ Staff and management are always approachable.” St George`s Home DS0000064009.V377844.R01.S.doc Version 5.3 Page 17 A complaints and suggestion box is also available for residents and visitors to use if the wish. A complaints log was maintained by the home and this showed that complaints had been appropriately addressed and managed. This gives people the confidence that their concerns will be listened to and acted upon. All staff undertake training regarding safeguarding to enable them to identify abuse and to know what to do if they witness or suspect it. The home uses the Local Authority safeguarding policy. The manager tells us in the AQAA in response to being asked how the home had improved in this section, “Policies and procedures relating to adult safeguarding are in place and are clear and easy to understand.” The home had two incidents that were referred to the safeguarding team since the previous inspection. These were investigated and resolved. The recruitment practice minimises the risk of the employment of unsuitable people, thereby safeguarding residents. St George`s Home DS0000064009.V377844.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home offers the people living there comfortable surroundings, which are clean, free of offensive odour and generally safe and well maintained but with some shortfalls in the bedroom furniture. EVIDENCE: There have been some environmental improvements since the previous inspection. These include, as previously mentioned, safe and appropriate medication storage has been provided; new and attractive light fittings and ceiling tiles in the lounge areas and dining room that add to the comfort of the people living in the home; new furniture in the porch making the entrance more welcoming; new carpet in some bedrooms; two towel rails have been St George`s Home DS0000064009.V377844.R01.S.doc Version 5.3 Page 19 provided in shared room and toiletries were named to minimise the sharing of towels and toiletries, thereby minimising the risk of cross infection; unused items previously stored on corridors had been disposed of; the dining room had been painted with one wall in a warm burgundy although would have been improved by the wallpaper being replaced before painting. Matching burgundy table linen has also been provided making the room an attractive place for people to take their meals. New furniture is now available in the garden and residents have been able to sit out when the weather has permitted. Most of the other surroundings remain unchanged with three lounge areas and a large dining room which are all open plan. There is a television in each lounge area but it difficult for them to be showing anything other than the same programme due to the open plan arrangement. One of the televisions has a large screen, which is helpful for those residents with any visual impairment. Although the majority of the furniture in the home is of a satisfactory standard, furniture in several bedrooms continues to look shabby and dated. There were no other maintenance needs identified. The laundry equipment has been replaced by more suitable industrial machines with the appropriate washing programmes to ensure hygiene and infection control. The laundry area is cleaner and tidier than previously. All areas of the home visited were clean and apart from a faint smell of urine in some bedrooms the majority of the home was free of any offensive odour. Staff are provided with protective clothing, disposable gloves and aprons to use when necessary to prevent cross infection. Appropriate hand washing facilities with disposable towels and soap dispensers are provided in communal hand washing areas, and alcohol gel is readily available, so that infection control is maintained. Staff have undertaken Infection Control Training and are taking part in the Health Care Associated Infections (outside of hospitals) programme to raise the standards of hygiene and cleanliness of the home. The manager told us in discussion and in the AQAA that the home is also involved in promoting the “hand wash technique campaign amongst staff, service users and visitors”. St George`s Home DS0000064009.V377844.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are sufficient staff available to meet the needs of the residents. Satisfactory recruitment practice protects residents from the employment of unsuitable people. The importance of training is recognised. EVIDENCE: Observations, discussion with the manager, staff and residents and inspection of the staff rotas indicated that there are sufficient care and ancillary staff at the home each day to meet the needs of the people living at the home. Records showed us that 83 of the care staff have achieved the National Vocational Qualification (NVQ) Level 2 or 3 in Care, and two care staff are registered nurses, well exceeding the minimum requirement of 50 . This qualification means that staff have been trained and assessed as competent in their role. St George`s Home DS0000064009.V377844.R01.S.doc Version 5.3 Page 21 Three staff files were looked at to assess the recruitment procedure and practice of the home. Two of these contained the appropriate Protection of Vulnerable Adults (POVA) First checks and the Criminal Records Bureau (CRB) disclosures, two written references and evidence that there had been a formal recruitment process. However one recently appointed member of staff had all these documents, including the POVA First check, in their staff file apart from the CRB disclosure. Whilst the manager was able to say what steps were taken to minimise any risk until this document had been received this had not been recorded. The manager sent us these recorded details, which safeguarded residents, immediately following the inspection. There was evidence in the records looked at to demonstrate that new staff undertake induction training to enable them to be able to carry out their job in a safe and effective manner. Other training undertaken by staff includes mandatory training, SOVA (safeguarding of Vulnerable Adults), Health and Safety, First Aid, Fire Safety and Moving and Handling. There are plans for dementia training for all staff. St George`s Home DS0000064009.V377844.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A person undertaking the appropriate qualification and who has extensive management experience manages the home. Monitoring and auditing of the service and practices ensure that all services operate in the best interests of residents. Health and safety practice protect residents and staff at the home. EVIDENCE: The registered manager has achieved NVQ Level 4 in Management and is St George`s Home DS0000064009.V377844.R01.S.doc Version 5.3 Page 23 undertaking the Registered Managers Award. This will give her the appropriate qualification for her role and ensure that she has the necessary up to date skills and knowledge. She has been at the home for twenty years and provides stable leadership and continuity. Surveys are distributed by the home to residents, relatives, staff and professionals for their feedback about the services provided. There are also regular meetings with residents, relatives and staff which give further opportunity for feed back and to communicate any necessary action. The home owner visits the home regularly and at monthly intervals carries out an inspection following which he provides a report for us and the manager. Monitoring and auditing of the service and practices ensure that all services operate in the best interests of residents. Some money is kept on behalf of residents, which is kept in a secure location. There were appropriate records of all transactions and cash balanced against these records. Receipts for any spending were kept with these records. The system protects the financial interests of the people whose money is being looked after. There are electrically operated security gates and four CCTV cameras in the grounds to safeguard residents from intruders. They also protect those people who have limited understanding and lack awareness of their own safety from the busy adjacent road. All staff undertake training related to health and safety issues. There was evidence from a random check of records, that equipment was regularly serviced and maintained, health and safety checks were carried out and that in house checks on the fire system were up to date. There were no health and safety issues noted at the visit. Health and safety practices protect residents and staff at the home. St George`s Home DS0000064009.V377844.R01.S.doc Version 5.3 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 x x x x x 3 STAFFING Standard No Score 27 3 28 4 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 St George`s Home DS0000064009.V377844.R01.S.doc Version 5.3 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP7 OP19 OP20 OP26 OP31 Good Practice Recommendations Assessments and care plans should cover all areas of need including cultural and religious needs. The bedroom furniture should be of a satisfactory standard in all bedrooms. Consideration should be given to making the communal areas into more homely proportions. Any offensive odour in the home should be addressed. The registered manager should complete the Registered Managers Award as soon as possible. St George`s Home DS0000064009.V377844.R01.S.doc Version 5.3 Page 26 Care Quality Commission Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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