Inspection on 21/05/07 for St John`s Residential Care Home

This inspection was carried out on 21st May 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St John`s Residential Care Home 23/05/06

St John`s Residential Care Home 22/06/05

St John`s Residential Care Home 09/05/05

St John`s Residential Care Home 08/12/04

St John`s Residential Care Home 05/05/04

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE St John`s Residential Care Home 66 Hawthorn Bank Spalding Lincs PE11 1JQ Lead Inspector Sue Hayward Key Unannounced Inspection 21st May 2007 12:15 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 John`s Residential Care Home DS0000002421.V337426.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 John`s Residential Care Home DS0000002421.V337426.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St John`s Residential Care Home Address 66 Hawthorn Bank Spalding Lincs PE11 1JQ 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) 01775 710567 01775 714147 www.countrycourtcarehomes.com Mr Abdulaziz Ali Kachra Helen Finlay Care Home 55 Category(ies) of Dementia (55), Mental disorder, excluding registration, with number learning disability or dementia (4), Old age, not of places falling within any other category (55) St John`s Residential Care Home DS0000002421.V337426.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide personal care for up to 55 service users of both sexes whose primary needs fall within the following categories:Old age, not falling within any other category (OP) 55, Dementia (DE(E) 55 , Mental disorder, excluding learning disability or dementia (MD(E) 4. The maximum number of service users to be accommodated is 55. 2. Date of last inspection 23rd May 2006 Brief Description of the Service: St Johns Residential Care Home is a large Victorian building, formerly known as the Old Vicarage, which has been extended to provide additional accommodation. The accommodation is located on two floors, which are run as separate units. The home is registered to provide care for 55 service users who are in need of care due to dementia, needs associated with old age and up to 4 residents who have needs associated with mental health. The home is situated approximately one mile from the centre of the market town of Spalding, which has a wide range of amenities. The home has large grounds laid to lawns and flower- beds, with car parking situated to the side and rear of the property. The aim of the home is stated as to provide a customer focused service, meeting individual needs and preferences. Information provided prior to the inspection confirmed that current fees range from £348 - £550 per week. Charges for chiropody, hairdressing, newspapers and personal toiletries are additional to the fees. The certificate giving important information about the terms and conditions of registration is on display in the entrance hall. A copy of the most recent published inspection report can also be found there. St John`s Residential Care Home DS0000002421.V337426.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to the home was undertaken by one inspector and formed part of a key inspection. The visit lasted eight hours and took into account previous information held by the Commission for Social Care Inspection (CSCI) including previous inspection reports, the history of the service and records of any incidents that had been notified to the CSCI since the last inspection. Prior to the visit ‘Have your say about’ questionnaires were received from fourteen people, all had been completed with the support of staff or relatives. In addition a pre-inspection questionnaire, completed by the manager giving important information about the service was received prior to the visit and information from this was also used in the compilation of this report. A previous visit had been made on 18th October 2006 to check on the progress made towards resolving issues raised at the inspection of 4th April 2006 and to look into a concern raised with the CSCI through the inspection process. This visit consisted of following the care of five residents through their records, talking to three of them, and to three staff members on duty. In addition two sets of relatives who were visiting during the inspection were spoken to and staff were observed at different times whilst assisting residents. The visit focussed on key standards, which have the potential to affect residents’ health, safety and welfare. The manager was present for part of the visit present and discussion was held with her and a company representative about the findings at the end of the visit. What the service does well: The home is clean and tidy and residents are able to make their rooms more homely if they wish with their own personal effects. Visitors are made to feel welcome and information is on display about the home and any events arranged for people to refer to if they wish. Care records are well organised and maintained and provide sufficient information to enable staff to provide appropriate care. The health care of residents is promoted. St John`s Residential Care Home DS0000002421.V337426.R01.S.doc Version 5.2 Page 6 Comments such as “I am very happy here and very happy with the care “, “ I am very content” and “I enjoy talking to the staff and since I have been here I don’t feel lonely” give an indication of peoples satisfaction with the care provided. 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. St John`s Residential Care Home DS0000002421.V337426.R01.S.doc Version 5.2 Page 7 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 John`s Residential Care Home DS0000002421.V337426.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 John`s Residential Care Home DS0000002421.V337426.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3. Standard 6 does not apply. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are satisfactory systems in place to introduce and assess residents to ensure residents care needs are identified and can be met prior to admission. Information about the home is readily available. EVIDENCE: Information about the home was on display in the entrance hall. A guide to the home was also on display in each resident’s bedroom checked on this occasion. Information is available in large print. Out of the questionnaires that had been completed on behalf of residents by staff or their relatives the majority were of the opinion that they had received sufficient information about the home and had received information about the terms and conditions St John`s Residential Care Home DS0000002421.V337426.R01.S.doc Version 5.2 Page 10 of their stay. The records of three residents who had been admitted to the home in the past eight months were checked on this occasion. They demonstrated that there had been an assessment of their needs made prior to their admission to the home to ensure that their needs could be met at the home. This included assessments of any risks such as those associated with their mobility and how to minimise them. Information had also been obtained from other relevant professionals such as social services to help plan the care of residents. Assessment information was in sufficient detail to enable a plan of care to be drawn identifying residents’ needs. Discussion indicated that relatives had been involved with their relatives’ admission to the home as well and the manager confirmed that there are policies relating to admission and discharge. All residents records checked on this occasion contained a letter confirming the outcome of the assessment. Discussion with staff indicated that they had a good knowledge of residents’ needs and how to meet them. Residents’ comments were positive about the care and support they received. A certificate, which gives information about registration terms and conditions, is also on display in the front entrance hall. St John`s Residential Care Home DS0000002421.V337426.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are well organised and reflect the individual needs of residents and how to meet them to ensure their health and welfare. Medication is managed in a satisfactory way, which promotes the safety of residents EVIDENCE: All residents records checked on this occasion were well organised and contained a plan of care with documented evidence that care was being reviewed on a regular basis. Many of the residents are very dependent and are unable to be fully involved with the development of their care plans. In such circumstances the manager said relatives or residents’ representatives are invited to sign to acknowledge their involvement and agreement to the care plan. Although signatures had not been obtained on three of the records St John`s Residential Care Home DS0000002421.V337426.R01.S.doc Version 5.2 Page 12 checked letters were on file requesting relatives read and sign care plans on behalf of residents. Care plans contained a good range of information about residents’ needs and how to meet them. The ones checked identified whether there were any specific matters such as communication, dietary, medication or health needs. Where necessary, assessments were in place confirming the actions needed to reduce any risks to ensure residents’ safety. For example a record checked demonstrated that the use of bed guards had been assessed and agreed to. Staff had a good knowledge of residents needs. Residents looked well cared for and made comments confirming they were. There was a range of equipment in place to meet residents needs, such as air flow mattresses to promote good skin care and equipment such as slings and hoists to ensure residents safety should they need help to move. Comments from questionnaires indicated that with the exception of one all felt that they “usually or always” received the medical attention they needed. Care records showed that residents’ health was monitored regularly and appointments made with other health professionals as needed. Staff ensure residents receive their medication at appropriate times as none of the current residents self-medicate. Discussion and observation of a staff member administering medication indicated a safe procedure is followed to protect residents. Records were satisfactorily completed and records and discussion with staff demonstrated that they have had training in medication administration. Discussion and records checked demonstrated that the home has a contract with a pharmacist who makes regular visits to advise on the system in place. A resident made a comment that staff respected her privacy and dignity and there are policies relating to basic care values in place. Questionnaires confirmed residents “always” or “usually” received the support they needed. A comment such as “I am very happy with the care” demonstrated a resident ‘s satisfaction with the care provided. St John`s Residential Care Home DS0000002421.V337426.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): Standards 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is variation in how well residents social and recreational needs are met but they are supported to have choice in their daily lives and visitors are made welcome. The meals provided are well balanced and take into account residents personal preferences and special dietary requirements to ensure their welfare. EVIDENCE: There are notices on display advertising planned events such as a strawberry tea and records are kept of activities that take place. Those seen for the week of 8th May 2007 indicated that a range of activities had been provided which included manicures, board games, hand massages, music and movement, a film night, bingo and card games. A resident was involved in a game of cards and craft projects were on display. St John`s Residential Care Home DS0000002421.V337426.R01.S.doc Version 5.2 Page 14 The records of residents whose care was being followed detailed their hobbies, religious and cultural needs and individual preferences such as times of getting up and retiring to bed and food preferences. Comments from questionnaires varied about whether activities were arranged that residents could participate in. For example “there is always something going on” and “ I would like to see more activities in the afternoon and evening”. The manager acknowledged as the activities co-ordinator had recently left this may account for the varied comments but the post, which is for 15 hours per week, is being advertised. The company also employs the services of an occupational therapist to assess residents’ abilities, so that activities can be planned which meet individual needs. Comments from residents on the day were positive about the meals provided for example a resident said, “the meals are good and if you don’t like it they will get you something else”. Jugs of cold drinks were available in dining rooms and lounges. Staff were encouraging more dependent residents to eat their teatime meal and whilst most residents were in the dining room others were in the lounge as staff said that was where they preferred to have their meal. Comments from questionnaires included, “dinner time is quite a good selection of varieties but teatime always seems to be sandwiches”, “meals are always very nice and “I understand my mother-in-law enjoys her food. She needs feeding and the staff are very kind”. Menus were checked and it was noticed that a selection of sandwiches is available daily at teatime, but there are other choices as well such as beans on toast, sausage rolls and teacakes. The cook confirmed that residents are asked about their particular food preferences and if they are unable to give this information they try and involve relatives. She said she had attended a course recently in relation to food safety. The home has achieved an award from South Holland District Council indicating good kitchen standards are maintained. Staff were well aware of those residents with specific dietary requirements. Good records are kept to monitor weight to ensure residents welfare and during the staff changeover information was shared about concerns staff had in relation to such a matter and how it was being addressed. Residents and relatives said they were able to receive visitors when they wished. A visitor said he was always made to feel welcome and was offered a drink and a sandwich as he generally visited at teatime. St John`s Residential Care Home DS0000002421.V337426.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are satisfactory systems in place to raise concerns and as far as possible protect residents from abuse. EVIDENCE: Two complaints had been raised with staff since in the past twelve months. These had been appropriately recorded and demonstrated that actions had been taken to address and resolve them. One of these concerns had also been raised with the commission. This related to the support provided to residents, the cleanliness of the home and activities. These issues were looked at during the inspection of 10th October 2006. No legal requirements were made as a result of this inspection although good practice recommendations were made about ensuring the serving of food to residents who require assistance be reviewed to ensure that they receive a prompt service and that jugs of drinks are available for residents. Observations made during this visit indicated both of these recommendations have been addressed. Both discussions with residents on the day and the responses from questionnaires confirmed in all but one instance that they knew who to speak to if they were St John`s Residential Care Home DS0000002421.V337426.R01.S.doc Version 5.2 Page 16 unhappy and how to make a complaint for example one comment was “I usually speak to the floor manager” another “there are always staff around to talk to” and “I am very happy here and very happy with the care”. Staff said that for residents who are less able to raise concerns themselves they would rely on their knowledge and observations of residents to indicate whether there may be concerns. Staff members had good knowledge of both complaints and safeguarding adult procedures supported by safeguarding adults training sessions and written policies. A copy of Lincolnshire County Councils safeguarding adults procedure was in place and available for staff to refer to if needed. Due to the dependency needs of some residents the responsibility for safekeeping their money or valuables is undertaken by staff. A check was made in respect of this on two of the people whose care was being followed. This confirmed there are good procedures in place, which ensure the administration and storage arrangements of money or valuables protect and as far as possible safeguard residents’ interests. St John`s Residential Care Home DS0000002421.V337426.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 22 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean and hygienic and provides residents with a comfortable and safe environment. EVIDENCE: All areas of the home seen were clean and tidy. A range of equipment was seen around the home and bedrooms were furnished and equipped to meet resident’s individual needs. Call bells were in each room seen and heard to be in working order. For those residents who are unable to use them staff said they try to be with them as much as possible. Residents’ made comments that they were satisfied with the comfort the home provides. During discussion with one another resident wandered into the bedroom uninvited. The resident St John`s Residential Care Home DS0000002421.V337426.R01.S.doc Version 5.2 Page 18 whose room had been entered confirmed that this was a common occurrence. She confirmed she is able to lock her room if she wishes. Whilst bedroom doors have signs it is recommended that further consideration is given to ways in which residents can locate rooms to ensure residents privacy is protected. The front entrance is being decorated. There is an ongoing programme of redecoration, which has included lounge and dining rooms and some bedrooms. The company employ a maintenance person and staff confirmed that issues are generally dealt with promptly. Records are kept of any maintenance issues although it was noticed that some window catches needed repair, which had not been reported, and a bathroom lock was not working. Questionnaires were positive about the cleanliness of the home and satisfaction with the accommodation. For example “I like my room” and “I think the home is very clean”. Bedrooms were individually furnished and equipped to meet residents’ needs. Residents confirmed they are able to bring with them some of their own personal items to help make their rooms more homely and described their beds as comfortable. There are policies and procedures in place relating to good infection control practices and equipment such as gloves and aprons available for staff to use to promote this. Records are kept to demonstrate areas within the environment, which have been assessed so as to ensure residents safety. St John`s Residential Care Home DS0000002421.V337426.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The current needs of residents are being adequately met by the staffing arrangements in place. Staff are trained to ensure they have the knowledge and skills to provide the appropriate care for residents, although the lack of staff that have had formal first aid training has the potential to put residents at risk. Residents are as far as possible protected by a thorough staff recruitment process. EVIDENCE: Comments were made such as “the staff are very good”, “ I enjoy talking to the staff and since I have been here I don’t feel lonely”, staff are very nice” and “I like all the staff”. Comments contained in questionnaires about the quality of the service confirmed that 13 were of the opinion that staff were “always or usually” available when needed although one thought staff were only available “sometimes”. There are currently 38 residents in the home. Six staff are employed on each shift, three covering each floor. Staff comments St John`s Residential Care Home DS0000002421.V337426.R01.S.doc Version 5.2 Page 20 about whether numbers were adequate to meet residents needs varied. A comment made was numbers were satisfactory unless two staff members were needed to assist a resident which then left one staff member to care for the needs of the remaining people during that time. Discussion with the manager confirmed that there is flexibility with staff between each floor and staff should be aware that they could ask for support when needed. She agreed that staff would be reminded of this. Consideration has also been given to ensuring staff are on duty on each shift who are able to communicate with a resident whose first language is not English. There is a rolling programme of training to ensure staff have the knowledge and skills to provide the appropriate care for residents. Training opportunities so far this year have included updates about manual handling, fire safety, health and safety, adult protection, infection control, dementia, medication administration and adult protection. Information prior to the visits indicated that only 1 person had achieved a first aid certificate although the manager confirmed training about this was being arranged. As the majority of residents have medium or high dependency needs it is important that staff are kept up to date with first aid procedures although, those staff asked had a satisfactory knowledge of the action to take if a resident had an accident. Following this visit the manager confirmed during a telephone discussion that training had been arranged to take place on 17th July 2007. 15 staff have now achieved a nationally recognised vocational award in care at level 2 or above. There is also a programme in place to train newly employed staff about the work. This includes basic care principles such as respecting the dignity and privacy of residents and ways of communicating. The majority of staff were confident and sensitive in how they dealt with residents needs. One was less confident when dealing with a resident who was shouting. The manager and company representative agreed to address this further through training. The records of 5 newly employed staff were inspected. All contained information to demonstrate that there is a satisfactory recruitment process in operation, with the necessary documentation to ensure the protection of residents, such as criminal records bureau checks. A visitor confirmed that staff kept them well informed about their relatives welfare and were generally available to speak to when they visited. St John`s Residential Care Home DS0000002421.V337426.R01.S.doc Version 5.2 Page 21 Staff members spoken to indicated they felt valued in their work via the formal and informal systems in place to support them such as bi-monthly meetings with senior staff. St John`s Residential Care Home DS0000002421.V337426.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): Standards 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is being effectively managed and led to ensure that the health, safety and welfare of residents is promoted. EVIDENCE: There has been no changes to the management arrangements in the past year. The manager is a qualified nurse and is in the process of working towards a nationally recognised vocational award at level 4 in management. A resident said “ I like it here”, she could not think of any way that the care or accommodation could be improved for her. Another said, “ it is good here and St John`s Residential Care Home DS0000002421.V337426.R01.S.doc Version 5.2 Page 23 I feel safe”. Of the 14 questionnaires that had been completed by residents or their relatives, 12 said they knew who to speak to if they were unhappy and how to make a complaint. In the absence of the manager, senior care staff are in charge of shifts, with an “on-call” system being operated should they need to seek advice. Staff spoken to felt well supported by the manager and confirmed there are formal and informal systems in place to receive advice and guidance such as staff supervision and appraisal. There are a range of policies and procedures, which are easily available for staff to refer to if needed covering aspects such as residents’ personal care and health and safety matters. Records are in place demonstrating that risks have been assessed relating both to individuals and the environment in order that action can be taken to minimise them. Some maintenance records were checked. All those checked were satisfactory and demonstrated that matters relating to health and safety were regularly checked. There are various methods in place to check on the quality of the service for example a company representative visits the home and provides a report on the standard of service being provided. Questionnaires are used with residents and relatives to obtain their comments about the standard of the service and records are kept of any concerns or complaints raised. It was also observed that notices were on display inviting relatives and residents to a meeting if they wished where they can have the opportunity to raise any issues. Notes of staff meetings were also available indicating that the last one was held on 20th September 2006. Those records that must be kept by law were well maintained and organised. For example, records of any money held on behalf of residents were up to date, accurate and included periodic checks to ensure their accuracy. St John`s Residential Care Home DS0000002421.V337426.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X X 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 St John`s Residential Care Home DS0000002421.V337426.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP30 Regulation 13 (4) Requirement There must be at least one first aid trained person in the home at all times, to make sure that people who use the service receive appropriate treatment if they have an accident. Timescale for action 31/07/07 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 OP22 Good Practice Recommendations Ways in which the privacy and dignity of people who use the service can be better protected should be explored to enable people to more easily identify their own rooms. St John`s Residential Care Home DS0000002421.V337426.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Lincolnshire Area Office Unity House The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 John`s Residential Care Home DS0000002421.V337426.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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