Inspection on 14/11/06 for St Joseph`s Nursing Home

This inspection was carried out on 14th November 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Joseph`s Nursing Home 15/11/05

St Joseph`s Nursing Home 14/06/05

St Joseph`s Nursing Home 13/12/04

St Joseph`s Nursing Home 21/06/04

St Joseph`s Nursing Home 09/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE St Joseph`s Nursing Home 52 Plymouth Grove West Longsight Manchester M13 OAR Lead Inspector Geraldine Blow Key Unannounced Inspection 09:30 14th November 2006 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 Joseph`s Nursing Home DS0000021581.V301388.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 Joseph`s Nursing Home DS0000021581.V301388.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Joseph`s Nursing Home Address 52 Plymouth Grove West Longsight Manchester M13 OAR 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) 0161 273 4147 0161 273 2162 Little Sisters of the poor Sister Josephine Storey Care Home 53 Category(ies) of Old age, not falling within any other category registration, with number (53) of places St Joseph`s Nursing Home DS0000021581.V301388.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. All service users are 60 years or over. The maximum number of service users requiring nursing care will be 13. These service users are accommodated on the ground floor. Three named service users requiring nursing care are currently accommodated on the first floor. When these service users no longer require this accommodation the first floor will revert to accommodating service users requiring personal care only. 15th November 2005 Date of last inspection Brief Description of the Service: St Josephs Nursing Home is registered to accommodate 13 residents assessed as requiring nursing care and a maximum of 40 residents assessed as requiring personal care only. The home is owned and run by The Little Sisters of the Poor. The home is located in Longsight just south of Manchester City Centre. Local facilities and bus routes are within easy walking distance. The home provides ample secure parking facilities at the front of the building. The home is a three storey purpose-built building set in large, secure, wellmaintained grounds. The home is divided into 3 units and a wide variety of communal areas are available for residents. Bedroom and communal accommodation for the residents is provided on the ground floor and the first floor. All rooms are single and provide en-suite facilities. The second floor provides living accommodation for the Sisters. A daily mass is held in the chapel and for those residents who are unable to attend the chapel morning mass can be accessed via a special TV channel direct to their bedroom if they wish. The charges for fees range from £378.84 to £404.40 per week. There are additional charges for hairdressing, personal toiletries, newspapers and private telephones. St Joseph`s Nursing Home DS0000021581.V301388.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on information gathered by Commission for Social Care Inspection (CSCI) since the last inspection on 15 November 2005 and some supporting information received in the pre-inspection questionnaire submitted by the home prior to this visit and 4 returned residents comment cards. This visit was unannounced and forms part of the overall inspection process and it took place on Tuesday 14 November 2006. The opportunity was taken to look at all the key standards of the National Minimum Standards (NMS) and the requirement made at the inspection in November 2005. This inspection was also used to decide how often the home is to be visited to make sure that it meets the required standards. As part of the visit time was spent talking with the manager, residents, several members of staff, assessing relevant documents and files and a tour of the premises was undertaken. The CSCI are trying to improve the way we engage with people who use services so we gain a real understanding of their views and experiences of social care services. We are currently testing a method of working where ‘experts by experience’ are an important part of the inspection team and help inspectors get a picture of what it is like to live in or use a social care service. The term ‘experts by experience’ used in this report describes people who have been appointed by Help the Aged, under the direction of the Commission for Social care inspection, to take part in the inspection of services for older people. Mr Tommy Walsh, an expert by experience joined the inspector on this site visit. Mr Walsh spoke to residents, had lunch with the residents and observed resident and staff interactions and his comments and observations have been added to this report. The requirements from the previous inspection, with the exception on one, had been addressed and there was evidence that the home was continuing to work hard to develop the service. St Joseph`s Nursing Home DS0000021581.V301388.R01.S.doc Version 5.2 Page 6 What the service does well: The home continued to provide a clean, pleasant environment for the residents who live there. The standard of décor, furnishings and facilities throughout the home were of a very high standard. The home is divided into 3 units. Between the 3 units the home provided a smoking room, 2 small kitchen/dining rooms, and one large dining room. There were 9 lounge areas between the 2 floors and several seating areas throughout the home. There are also large, attractive, well maintained grounds with a variety of garden areas which were safe and accessible to residents in wheel chairs. The home also had a Chapel, a large concert hall, a library, a craft room, a small shop, a tea bar with 2 seating areas, a treatment room for physiotherapy and chiropody, a hairdressers and a laundrette on each floor as well as the main laundry rooms. The atmosphere in the home felt happy and relaxed. Residents were seen to be talking and laughing over lunch together. Comments regarding staff were all positive. Returned comment cards had statements like, “ the staff are very caring and kind. They look after me very well” and “ the care received is first class”. “The Sisters and staff are always very attentive”. One residents spoken to said “the staff are very kind” and another resident said, “this is the nearest place to heaven on earth”. The Expert by Experience said that all the residents he spoke to were very happy to be living there and they had nothing but praise for how the home was run. One resident said that in his opinion “it was the nearest thing to paradise”. One person who used to live at the home told the inspector that “this home is first class and everything in the home is first class”. He said there is a great family spirit in the home and residents help each other whenever they can. He also said the Sisters and the staff are first class and really look after the residents. From observations made and from talking to staff it appeared that the privacy and dignity of residents was protected and that residents were able to have choice with regard to their every day life. When bathrooms and toilets are in use “do not disturb” signs are displayed. The home carries out a pre admission assessments before a resident is admitted to the home to make sure that the home can meet the person’s needs and where possible, prospective residents and their family/representative are encouraged to view the home prior to making a decision about admission. Each resident had a detailed plan of care, which sets out in detail how that care is to be delivered and that medication is given safely. St Joseph`s Nursing Home DS0000021581.V301388.R01.S.doc Version 5.2 Page 7 The home had an open visiting policy and residents spoken to confirmed this. One resident said “my visitors can come whenever they want and we can go any anywhere in the home or stay in my own room”. A menu was on display outside the dining rooms and choice of meals was available at each mealtime. Residents spoken to, and feedback from the returned comments cards demonstrated that residents were happy with the quality and quantity of food. One comment was “ the food suites my tastes and is prepared to be easy for me to eat. We have plenty of my favourites too”. Residents spoken to said that drinks and small snack’s were available on request. On the day of this visit the Expert by Experience joined the residents for lunch and the Expert commented that the meal was “really well cooked and there was plenty of it, the portions were quite generous including seconds”. He also said there was a good variety and although he had a hot meal he was offered ham salad alongside the meal. The Expert also said that the “dining room was really modern and the tablecloths, chairs and curtains all matched”. The Expert said he “cannot praise enough the quantity and quality of the meal”. The home provided a wide range of activities, which was supported by the findings of the Expert by Experience. He commented that a number of activities were carried out at the home including armchair exercises, there was also a small group who play Whist. Birthdays were always celebrated at no cost to the residents and recently they held an Autumn Fayre. The statutory Bingo session are held on Fridays and they have special events like Race Nights, where the residents are shown a film of a horse race and they place bets before the race starts and hopefully back the right horse. A lot of the activities were organised by a local group of volunteers who become involved in fund raising. Each year they have a Flag Day in Manchester, which raises a considerable amount of money for the home. The residents and staff had recently celebrated the 50th Anniversary of one of the Nuns taking her vows and I saw photographs of the event. The staff had dressed, as Nuns and performed songs from the show My Fair Lady, and all seemed to be really enjoying themselves. The expert said he also spoke to one of the residents who was 100 years old and she was very chirpy and lovely to talk to. The home offered and encouraged training for staff to ensure that they have the necessary skills to meet the needs of the residents accommodated. Systems were in place to support residents or visitors to make a complaint. Residents and the visitor spoken to confirmed this and the returned comment cards also supported this. One comment was “complaints are quickly dealt with” and one resident said “any concerns I have had over the years have always been sorted out”. The home had a robust recruitment procedure to ensure that staff employed are safe to work with residents. St Joseph`s Nursing Home DS0000021581.V301388.R01.S.doc Version 5.2 Page 8 The Expert said, “staff all spoke well of the home and how much they enjoyed working there and not one of them was critical in any way”. It was encouraging that after spending the morning with the residents and observing staff interaction the expert by experience said that the “relationship between staff and residents was very heart warming”. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Joseph`s Nursing Home DS0000021581.V301388.R01.S.doc Version 5.2 Page 9 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 Joseph`s Nursing Home DS0000021581.V301388.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The home undertakes an assessment of prospective residents’ care needs prior to their admission. EVIDENCE: The home had a documented pre admission assessment form that was used to ensure that prospective residents were only admitted on the basis of a full assessment and evidence was seen that for residents who were referred through Care Management arrangements the home obtained a summary of the Care Management Assessment. It is recommended that following the pre admission assessment of a prospective resident the home confirms in writing to the resident that the home is able/not able to meet their assessed needs. St Joseph`s Nursing Home DS0000021581.V301388.R01.S.doc Version 5.2 Page 11 Where possible, prospective residents and their family/representative were encouraged to view the home prior to making a decision about admission. One comment card stated, “my daughter visited the home prior to my admission and told me about the high standards”. The home did not provide an intermediate care service St Joseph`s Nursing Home DS0000021581.V301388.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Individual plans of care were in place to ensure that residents’ health, personal and social care needs were fully met. The systems and procedures for dealing with medicines appeared to protect residents. EVIDENCE: A random sample of care plans were examined. The care plans examined had been generated from a needs assessment and the homes own care planning process. Each individual file was found to contain an assessment undertaken on admission and a care plan had been generated if appropriate. The plans of care were found to be detailed, informative and clearly set out the action that needed to be taken by staff to ensure that all aspects of health, personal, cultural, religious and social care needs of the residents were met. Appropriate risk assessments had been included and the plans of care had been regularly reviewed to reflect changing needs and current objectives for St Joseph`s Nursing Home DS0000021581.V301388.R01.S.doc Version 5.2 Page 13 health and personal care. Evidence was seen that the resident or their representative had been involved in the development of the care plans. Residents were seem to be registered with a General Practitioner (GP) and evidence was seen of referral to other specialised services according to individual assessed needs. A GP visited the home every week and had their own consulting room where residents could be seen. Residents could also be seen in the privacy of their own room if they prefer. Evidence was seen that the Medication Administration Recording (MAR) sheets were recorded accurately with the exception of prescribed creams and drink thickeners. Therefore the requirement made at the last inspection has been reiterated in this report. In order to ensure that residents care needs are being met when prescribed a thickener, (which is used to thicken drinks and soups for residents with swallowing impairment), an accurate record should be maintained of each drink / soup etc that has been thickened and any other liquid the residents have had to drink. It is essential that the person making the drink signs a sheet, this does not have to be the nurse and it does not have to be signed on the MAR sheet, a separate drinks recording sheet may be constructed for each resident. In addition it is recommended that individual instructions for each resident is readily and easily accessible to staff involved in the preparation of drinks / food for a resident. This was discussed with 2 of the qualified nurses. All deliveries and returns of prescribed medications had been recorded and accounted for, therefore providing a full audit trial. Medication, which had a limited life span, for example eye drops had a documented date of opening to help eliminate the risk of out of date medication being given to residents. The nurses told the inspector that the home had sight of the original prescription to check against the MAR’s and items received from the pharmacy. From observations made during the inspection and discussions with residents and members of staff it appeared that the nurses and care staff treated the residents with respect and dignity. St Joseph`s Nursing Home DS0000021581.V301388.R01.S.doc Version 5.2 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service Activities were provided and residents were able to maintain contact with family and friends. Meals served at the home were nutritious, well balanced and offered a healthy and varied diet for residents. EVIDENCE: Residents were consulted about their social interests and personal preferences by the completion of a personal history, which included significant life events, hobbies and interest, pets, religious and spiritual observance. As already stated in this report the home provided a wide range of activities which relatives and friends were encouraged to attend. Residents spoken to were looking forward to the Christmas activities that would take place. One resident said that “Christmas is lovely and we have lots of entertainment and go out to loads of places”. The manager said that the home did not currently employ a designated activity organiser but that it was her intention to do so. The home had a group of volunteers who regularly meet with staff and residents to discuss activities. The manager said that any activity a resident attended was recorded in the daily log sheets. St Joseph`s Nursing Home DS0000021581.V301388.R01.S.doc Version 5.2 Page 15 The Expert by Experience joined the morning service and said how much he had enjoyed the service and made comment on how beautiful the chapel was. The staff and residents confirmed that open visiting was facilitated and visitors could be received in the residents’ own room or any of the communal areas of the home. From observations and from speaking to staff and some residents it was evident that residents were encouraged to exercise choice and control over their day-to-day lives and that residents were encouraged to bring personal possessions into the home. The menu examined demonstrated that the home provided a varied diet, which was nutritionally balanced and included adequate supplies of fresh fruit and vegetables. There was a choice of food at each mealtime and any reasonable alternative to the menu is available on request. The residents were asked on a daily basis their choice of meals. Homemade cakes and tea were provided every afternoon. Feedback from the residents and the comment cards were all positive. A tour of the kitchen was made. The large kitchen was found to be clean and well organised. Large supplies of food were seen which included fresh fruit and vegetables. The chef manager said she had just had the delivery of ingredients ready to make the Christmas cakes and puddings. All food was seen to be stored appropriately. St Joseph`s Nursing Home DS0000021581.V301388.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The home encouraged and supported people to raise their concerns and complaints and had the policies, procedures and systems in place to protect residents from abuse. EVIDENCE: The home had a complaints procedure in place that was located in the residents’ library and in the policy folder on each unit. Residents received a copy, which was included in the Service User Guide, on admission to the home. The Commission for Social Care Inspection had not received any complaints about this service since the last inspection. A record was kept of all complaints made and included details of the investigation and any action taken. Residents spoken to confirmed that they feel comfortable if they had to make a complaint. One of the resident spoken to said that if she had a problem she would go to any of the Sisters. Evidence was seen that staff had received Protection of Vulnerable Adult (POVA) training. The home had policies relating to the Protection of Vulnerable Adults from Abuse and had a copy of the Manchester Multi-Agency Policy on the Protection of Vulnerable Adults from Abuse “No Secrets” guidance. Since the last inspection the home had received 2 allegations of abuse. An investigation had been completed and all appropriate action had been taken by the home. St Joseph`s Nursing Home DS0000021581.V301388.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service All areas of the home were clean, comfortable, well maintained and equipped to meet the needs of the residents. EVIDENCE: The home provided a clean, comfortable environment decorated and furnished to a high standard. There were a variety of communal areas for residents to use and large safe, enclosed grounds that were accessible to all residents. The Expert by Experience made comment that there was also a designated area for relatives to be entertained by the residents with plenty of good quality furniture and ample facilities for making a drink. Residents spoken to and information received from the comment cards indicated that the home was clean, tidy and odour free. Bedrooms were St Joseph`s Nursing Home DS0000021581.V301388.R01.S.doc Version 5.2 Page 18 nicely decorated and personalised with items brought in from resident’s own homes. The homes main laundry was situated on the ground floor corridor and contained appropriate washing and drying facilities. Dirty lined was transferred to the laundry in coded bins and soiled lined is transferred separately. The laundry has a dirty and a clean entry and exit system. Staff were specifically employed to work in the laundry. St Joseph`s Nursing Home DS0000021581.V301388.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service The number and deployment of staff appeared sufficient to meet the residents’ assessed needs. The procedures for recruiting staff were robust and appeared to provide adequate safeguards to protect residents. EVIDENCE: At the time of this visit the numbers and skill mix of the staff appeared to be sufficient to meet the needs of the residents accommodated. The home employed 42 care staff, 16 of which had achieved National Vocational Qualification (NVQ) level 2 and 3 members of staff had just recently completed NVQ Level 2. It was encouraging that the home had 3 NVQ Assessors on site. The staff files examined contained the appropriate documentation as required by Schedule 2 of The Care Homes Regulations 2001. It is commendable that the home employed an Induction Officer. The home had a structured induction that all new staff must complete. The induction had been reviewed and updated inline with the Skills for Care requirements. The Induction Officer had a record of all staff training and staff had an individual training and development plan. When individual training was due the Induction Officer puts up a notice on the employees notice board who is St Joseph`s Nursing Home DS0000021581.V301388.R01.S.doc Version 5.2 Page 20 due the training and when the training is available. On the day of this visit the home were facilitating catheter care training and because a new electric hoist had been bought the purchasing company were providing training in its use. The manager said that no new equipment was used until staff had received the appropriate training. St Joseph`s Nursing Home DS0000021581.V301388.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service The home is managed and operated in the best interests of the residents. EVIDENCE: Since the last inspection the manager has successfully been registered with theCSCI. The manager is a Registered General Nurse with a variety of nursing and management experience. She has undertaken a wide range of training including NVQ Level 4, Registered Managers Award. The manager clearly demonstrated the need to continually develop the care service in the best interests of the residents. St Joseph`s Nursing Home DS0000021581.V301388.R01.S.doc Version 5.2 Page 22 The home managed the personal allowance for some of the residents. There was a written record is kept of all transactions made and receipts were also kept. The manager said that it was her intention early in the New Year to send out questionnaires to residents, relatives and visiting professionals to the home in order to obtain their view on the quality of the service delivered. It is recommended that the manager then produce an annual development plan based on the results of the quality assurance questionnaire. The home had a set of policies and procedures that the homes development officer reviews and updates as required with input from the homes staff. Each unit had a copy of the policies and procedures for easy access. Evidence was provided that the home had appropriate service contracts in place for equipment and installations used in the home and that servicing was undertaken at the required intervals to ensure the safely of residents. Evidence was seen that appropriate fire safety checks were undertaken to ensure the safety of residents accommodated. St Joseph`s Nursing Home DS0000021581.V301388.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x x x x x x 4 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 3 x x 3 St Joseph`s Nursing Home DS0000021581.V301388.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes YES 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 OP9 Regulation 13 Requirement The person administering must sign for all prescribed medication. The previous timescale of 31/8/05 and 22/11/05 had not been met. Timescale for action 01/12/06 St Joseph`s Nursing Home DS0000021581.V301388.R01.S.doc Version 5.2 Page 25 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 OP3 Good Practice Recommendations It is recommended that following the pre admission assessment the home confirm in writing, to the prospective resident, that the home is able/not able to meet their assessed needs. 1. It is recommended that staff sign for all thickened drinks/soups given to a resident and that there is a sample list of signatures for those staff. 2. It is recommended that individual instructions for each resident requiring thickened drinks/soups is readily and easily accessible to staff involved in the preparation of drinks / food for a resident. 3. OP33 It is recommended that the manager produce an annual development plan based on the results of the quality assurance questionnaires. 2. OP9 St Joseph`s Nursing Home DS0000021581.V301388.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Joseph`s Nursing Home DS0000021581.V301388.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!