Inspection on 09/09/08 for St Martin`s House

This inspection was carried out on 9th September 2008.

CSCI found this care home to be providing an Adequate 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 Martin`s House 09/10/07

St Martin`s House 06/07/06

St Martin`s House 12/10/05

St Martin`s House 25/04/05

St Martin`s House 03/12/04

St Martin`s House 05/07/04

St Martin`s House 11/03/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Extracts from inspection reports are licensed from CQC, this page was updated on 13/11/2008.

CARE HOMES FOR OLDER PEOPLE St Martin`s House St Martins Crescent Camborne Cornwall TR14 7HJ Lead Inspector Mike Dennis Unannounced Inspection 9th September 2008 9:00 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 Martin`s House DS0000008910.V371934.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 Martin`s House DS0000008910.V371934.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Martin`s House Address St Martins Crescent Camborne Cornwall TR14 7HJ 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) 01209 713512 01209 711444 stmartins.home@cornwallcare.org Cornwall Care Ltd Vacant Care Home 40 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (22), Mental disorder, excluding learning of places disability or dementia (3), Mental Disorder, excluding learning disability or dementia - over 65 years of age (22), Old age, not falling within any other category (18), Physical disability (3), Physical disability over 65 years of age (18) St Martin`s House DS0000008910.V371934.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Service users to include up to 18 adults of old age (OP). Service users to include up to 18 adults with a physical disability (PD[E]). Service users to include up to 22 adults aged over 65 with a dementia (DE[E]). Service users to include up to 22 adults aged over 65 with a mental illness (MD[E]). Total number of service users not to exceed a maximum of 40. Up to 3 Service Users over the age of 59 and below the age of 65 in the categories Dementia (DE), Mental Disorder (MD) and Physical Disability (PD). The total number of Service Users not to exceed 40 9th October 2007 Date of last inspection Brief Description of the Service: St Martins House is one of eighteen care homes owned by Cornwall Care Ltd. It is registered to accommodate forty older people in need of personal care and nursing who are over retirement age. A limited number of people attend day care at the home. This care home with nursing provides long term care to service users who are in need of personal care and/or nursing care and are over retirement age. Admissions are planned and emergency admissions are avoided whenever possible. Day care is available at St Martins House for 1-3 service users a day. The facilities for residents are on a single floor, which is accessible to all service users. All service users rooms are single occupancy with access to lounge areas and toilet facilities. Service users can access a secure garden. St Martins House is close to the facilities of Camborne and has good transport links to the town. St Martin`s House DS0000008910.V371934.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 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced inspection took place over a period of approximately 7 hours on the 9th. September 2008. We met with the manager, staff, and residents, and toured the premises, as well as inspecting relevant documentation. The key inspection focused on the premises, meals, medication, records relating to care, staffing and management to include policies and procedures. Case tracking of five people took place and some of these people were spoken to during the course of the day. Mostly positive comments were received in relation to the care that they are receiving at the home. For example: “I get regular visitors and I like my privacy, which the staff respect”, “I get a choice of meals and have a nice room, I would not like to be anywhere else”. Some people spoken with thought that hygiene control could be improved and that staff should have more time available to embark on social interests with residents. It is noted that the physical care needs of a number of the people at St. Martins are high. The Manager completed the Annual Quality Assurance Assessment form. We are grateful to the manager, staff and residents for their assistance in completing the inspection. What the service does well: Staff told us that they receive a variety of good training, to include regular fire training, mental health training, induction training, medication training, venepuncture and Protection of Vulnerable Adults training. St Martin`s House DS0000008910.V371934.R01.S.doc Version 5.2 Page 6 They also said that they felt the staff team was working much better as a cohesive team. Residents told us that the majority of staff were excellent. They have the opportunity to engage with therapists on a one to one basis and also take part in various other activities and interests. The food provided is varied and to a good standard. Individual needs and choices are provided for. Employment policies and procedures are followed to ensure that vigorous checks are made as to the individuals suitability to work in a care environment. The manager has worked hard to improve the service provided. What has improved since the last inspection? The care staff are supportive of each other and are working well together. Comments from some quarters suggested that more staff would benefit the care delivery in the home. On the day of this unannounced inspection there were a total of 14 nursing and care staff on duty, which is considered to be ample in numbers for a home of this size. The new care planning format has now been introduced and is seen as working well. Records in general are well kept and up to date. Two new qualified nurses have recently been employed and we are encouraged with the work already undertaken to improve medication practices within the home. There have been some reported incidents leading to dissatisfaction from relatives. Cornwall Care have shared these problems with us and conducted full investigations to resolve the issues. St Martin`s House DS0000008910.V371934.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Martin`s House DS0000008910.V371934.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 Martin`s House DS0000008910.V371934.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): 1,2,3,5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s statement of purpose and service user guide documentation provide prospective people with details of what the home provides helping an informed decision about admission to the home. The manager assesses all people prior to admission to the home to ensure that the home will be able to meet their care needs. People may visit the home prior to admission. EVIDENCE: St Martin`s House DS0000008910.V371934.R01.S.doc Version 5.2 Page 10 Information is given to prospective residents by way of a Statement of Purpose, Service users Guide and brochure. We looked at these documents and found them to be up to date and they reflected the service being provided at the home. The Manager and senior nursing staff complete needs assessments for prospective residents and obtain assessments from the commissioning authority. Cornwall Care Ltd has a standard format for assessment and care planning, which, when completed in sufficient detail, covers all the issues specified in the standard. The five residents’ records case tracked in detail contained written needs assessments. Commissioning information from health and adult social care was also on file as were contracts and statements of terms and conditions. Assessments stated who was present, providing evidence that the prospective resident and their family were involved in the assessment. St Martin`s House DS0000008910.V371934.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): 7, 8, 9, 10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents health, personal and social care needs are set out in individual plans of care but not all have been regularly reviewed. Medication procedures are appropriately followed. The majority of residents report satisfaction with their health care. A minority of relatives/advocates were less satisfied. EVIDENCE: All the residents case tracked had written care plans. Cornwall Care Ltd has a standard single format for assessment and care planning. This system has been changed to the Standex System. All care recording in this home is now documented on this format. St Martin’s staff also draw up a ‘Care Profile’ - a summary of the care plan used as a working document. The care plans and St Martin`s House DS0000008910.V371934.R01.S.doc Version 5.2 Page 12 care profiles directed and informed care staff on meeting the health, personal and social care needs of residents. All residents case tracked had a moving and handling assessment. Falls risk assessments are compiled allowing staff to conduct overviews on these incidents. This information can feed into a review of the care plan. We noted that not all care plans had been reviewed at the required monthly intervals. There was a clear direction for staff about assistance with mobility. Daily records were completed consistently and generally to a good standard but sometimes lacked adequate detail. The daily records need to reflect everything that goes on in the home. More information concerning the social and emotional aspects of a residents life would be welcome. Staff keep separate daily records in respect of bathing, and, where required other specific individual care needs. Residents are all registered with local GP practices. The majority of residents and their representatives felt that their health care needs were well-monitored and appropriate attention obtained. A minority of relatives/advocates did not agree that that the care delivery was up to standard. The issues concerning these residents has been discussed with management. St. Martins does care for some very dependent people and it is recognised that the care input can be intense and challenging. Care planning and the consistent implementation of care delivery is therefore all important. Staff maintain a record of medical contacts for each resident. The community nurses visit the home regularly. Medicines are stored in locked trolleys and in locked cabinets in a locked room. The room and cabinets were tidy and well organised. There is a small medicines refrigerator and the temperature is checked daily. The monitored dosage system is in use. Some residents administer their own medication. Residents sign an agreement to the administration of medicines. Cornwall Care has a corporate policy and procedure on the handling of medicines which includes guidance on the use of homely remedies. We spoke with two of the senior nursing staff, both of whom have been recently employed. We are confident that they understand their role and their ideas shared with us bode well for the future. Given that this home now has nursing status, all medication should be administered by nursing staff. The provider has audited and improved systems for the storage, recording and administration of medicines that cannot be included in the monitored dosage system. The administration records were complete and well maintained. Samples of stocks were checked against the medicine administration record and found to be accurate. The controlled drugs are stored in a secure controlled drugs cabinet. A sample of controlled drugs was checked against the record and St Martin`s House DS0000008910.V371934.R01.S.doc Version 5.2 Page 13 found to be accurate. Unused/unwanted medicines are now disposed correctly via the appropriate disposal bins. Records are kept of all medication disposed. The temperature of the storage room must not to exceed 25C, this is now monitored. Creams/lactulose etc. are all contained in individually named pots. It was also positive to note that alcohol gel was available on the medication trolleys and being used. Residents provided positive comments on the skills and caring qualities of staff. They felt that staff worked sensitively with them when assisting with personal care and respected their privacy and dignity. Examples of staff delivering appropriate and sensitive care were noted during the inspection. St Martin`s House DS0000008910.V371934.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,14, 15 We have made this judgement using a range of evidence, including a visit to this service. ResidentsPeople who use the service experience good quality outcomes in this area. We h are supported to follow a lifestyle which accords as far as possible with their own choices and preferences. The diet provided is varied and nutritious with attention to individual preferences. EVIDENCE: The majority of residents commented that there is ‘enough to do’ during the day. A variety of activities were taking place or planned. These included socialising in lounges, tai chi and head massage, crafts, art, music, bingo, outings and receiving visitors. Staff discuss activities with residents so that they can choose whether to participate. Residents told us how much they enjoyed the activities. Some residents commented that they prefer to spend time in their own company and this is respected. Individual interests are recorded in service user admission information, care plans and their life story record. Some residents told us that there was insufficient attention and stimulation. We observed a high level of staff input to the nursing areas. The St Martin`s House DS0000008910.V371934.R01.S.doc Version 5.2 Page 15 care staff were also observed to be busy caring for residents. Some comments from visitors and residents claimed that staff seem to have less time for social interaction. There is a flexible visiting policy and residents determine where they meet their guests. Residents felt their visitors were welcomed to the home positively and could not think of improvements in this area. Visitors confirmed that the home’s visiting arrangements suit them and that generally staff make them welcome, offering, for example, a cup of tea. The Manager stated that she does not act as appointee for any resident for their benefits or manage any savings. A minority of residents manage their own finances. Other residents’ finances are managed with informal assistance from relatives or through Power of Attorney arrangements. Residents can bring in possessions and furniture by agreement with the provider. Cornwall Care Ltd has introduced the ‘appetite for life’ initiative to ensure that a varied and appealing diet is provided to residents in a relaxed atmosphere. The cook reported that they have continued to review their 4-week menu and take account of residents’ wishes. There are two main choices each day at lunch, with further choices also available. The home is currently providing some diabetic diets and low fat diets. Some residents receive assistance with eating. Residents made positive comments to us concerning the food provided to them. Staff were seen helping residents with their food intake. Residents choose where to have their meals, either in their room or in the wing dining area. Residents enjoyed a sherry or glass of wine and their choice of meal. Residents reported that they had a good choice of breakfast, and a range of savouries and puddings and cakes at tea. Drinks are served between meals. St Martin`s House DS0000008910.V371934.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. People who use 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 has a satisfactory complaints procedure that would ensure that complaints are listened to and acted upon. There are arrangements to protect service users from abuse. EVIDENCE: Cornwall Care Ltd has a corporate complaints procedure. Any complaints received at the home have been investigated by management personnel. The Manager keeps a record of compliments. Residents told us that they knew how to make a complaint. Residents and visitors told the inspector that they would approach the managers at the home with any concerns and these would be addressed. Cornwall Care Ltd has an adult protection policy and procedure. Cornwall Care staff in general respond appropriately to incidents and concerns about adult protection and follow the local Multi-Agency Adult Protection Guidelines. The company’s own policy and procedures are in line with Multi-agency St Martin`s House DS0000008910.V371934.R01.S.doc Version 5.2 Page 17 Safeguarding procedures. The majority of staff have received training in adult protection. St Martin`s House DS0000008910.V371934.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is generally well presented but some areas require attention to ensure that residents live in a well-maintained, clean and hygienic environment. EVIDENCE: The residents’ accommodation at St Martins House is on the ground floor and is accessible to all service users. A small area of the building is used for offices. The home is arranged in four wings. Each wing is a self-contained unit with bedrooms, dining area, lounge, toilets and bathrooms. There is a garden which is accessible to residents. Bedrooms are single occupancy. These rooms are quite small, but are pleasantly decorated and furnished. St Martin`s House DS0000008910.V371934.R01.S.doc Version 5.2 Page 19 St Martins is situated in a residential area of Camborne not far from the facilities and services of the town. The car park leads to the main entrance which is suitable for wheelchair users. The provider has a redecoration and maintenance programme aimed at ensuring that all parts of the home are presented and maintained to a good standard. Some areas of the home are in need of improvement as detailed below. In general the cleanliness of the home was to acceptable standards. We did observe some areas in residents rooms where this was not the case. In talking to staff, it was felt that the absence of domestic cover at weekends was not satisfactory and also that a kitchen domestic was essential. Residents stated that they are satisfied with the presentation and the quality of furnishings. The majority of rooms inspected were clean and decorated to a good standard. The rooms were personalised and residents had the option to lock their rooms. Each wing and bedrooms has an individual colour scheme as a form of signposting for residents. The laundry complies with the standard. The washing machines and tumbler driers are industrial standard. Guidance notices are posted for staff. Residents commented that the laundry service is ‘good’, with their clothes being kept clean, and did not raise any issues in this area. The bathing and toileting facilities in the home comply with the standard, providing assisted baths and a level entry shower. Toilets are suitably close to communal areas. All the bathrooms and toilets inspected were clean and hygienic. Facilities for hand washing with hand wash, paper towels and alcohol rub were situated throughout the home. Aids and adaptations were evident to assist with mobility and transfers. There were sufficient sluicing facilities in the home. We conducted a tour of the building between 9:00 and 9:30am. At this time several residents were having their breakfast and there were plenty of staff in attendance. Odour control throughout the home was satisfactory. Bathrooms and toilet areas were freshly cleaned and hazard warning notices were in place. Carpeting in many areas had yet to be vacuumed and it was noted that some were stained. We were told that a carpet cleaning program was scheduled for the end of the week. The kitchen area requires some attention. It was noted that the area is in need of a thorough “high” clean to ceilings, walls etc. High level windows are causing drip stains down the wall and onto work surfaces below. Some splash back tiles require replacement. The absence of a food preparation sink is causing problems for the cook although we understand a replacement is on order. St Martin`s House DS0000008910.V371934.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. People who use 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. Recruitment procedures support and protect the service users. Staff are trained and competent to meet the needs of residents. The staffing levels are generally satisfactory. EVIDENCE: Residents commented that they felt staffing levels were sufficient, although some remarked that staff were kept busy and that priority seemed to be given to the nursing residents. There has been an increase in staffing levels since the introduction of nursing care. Overall it is considered that staffing levels are satisfactory but care must be taken to ensure they are evenly dispersed throughout the home. No complaints came forward about the skills and qualities of the staff team. In fact we were told and observed a good team spirit amongst the staff team. Some said that more staff on duty would be an asset. On the day of this unannounced inspection we consider that the home was well staffed by management, nurses and care staff. A recent summary of training records showed that the majority of staff have achieved NVQ awards St Martin`s House DS0000008910.V371934.R01.S.doc Version 5.2 Page 21 Qualified nursing staff are employed and all are checked to have current registration through their governing body the NMC. The training records for nursing staff clearly identified their training needs. . All staff are recruited following set down company procedures. We tracked this process in respect of six staff and found that all had been competently managed to include application forms, references, proof of identity and CRB and POVA checks. Cornwall Care Ltd provides a structured training programme for staff. Training records showed that staff were up to date with required training in moving and handling, dementia care, food hygiene and health and safety. Recently appointed staff had begun their inductions. Staff made positive comments about the training they received to do their jobs. St Martin`s House DS0000008910.V371934.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37, 38. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has an experienced and qualified manager. The health and safety of residents and staff are generally promoted and protected as are their financial interests. There are areas where improvement can be achieved. EVIDENCE: St Martin`s House DS0000008910.V371934.R01.S.doc Version 5.2 Page 23 The home does not have a Registered Manager at this time. The previous deputy manager has been promoted and is in the process of submitting an application for registration. She is experienced and holds a Foundation Degree in Management, NVQ 4 and is an NVQ assessor. A new Lead Nurse has recently been appointed and also another senior nurse to compliment the nursing team. Cornwall Care Ltd has corporate policies for the management of service users’ monies. Service users are encouraged to manage their own monies and hold their own accounts. Cornwall Care Ltd provides safekeeping for small amounts of money. The records show all payments in and out and a running balance. The Manager reported that an inventory is now retained for all valuable items also held for safekeeping. Cornwall Care Ltd has previously sought the views of residents and their representatives, and other stakeholders through questionnaires. The last quality assurance survey was conducted in April of this year. We looked at the staff supervision records and also spoke to several care staff. The resulting conclusion being, that staff have not recently received regular supervision. Cornwall Care Ltd has comprehensive policies for health and safety. A sample were checked against the original records and found to be accurate. Staff have attended relevant health and safety training. Staff reported that Cornwall Care Ltd promotes safe working and manages health and safety well. There are however areas of hygiene relating to health risks which need attention as stated previously in this report. The records showed weekly tests of the fire alarm system, monthly tests of the emergency lighting and regular fire training for all staff. St Martin`s House DS0000008910.V371934.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 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 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 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 3 2 St Martin`s House DS0000008910.V371934.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Care plans are to be reviewed at monthly intervals and where practical any changes discussed with the individual concerned Staff are to receive supervision at least 6 times per year. Evidence must be recorded to confirm compliance Timescale for action 31/12/08 2. OP36 18 31/12/08 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 OP9 Good Practice Recommendations Qualified nursing staff should administer medication throughout the home. The kitchen area requires a thorough ‘high’ clean following which cleaning schedules to be adhered to. The re-distribution of domestic staff, to cover all 7 days DS0000008910.V371934.R01.S.doc Version 5.2 Page 26 2 3 OP26 OP38 St Martin`s House per week should be considered to ensure the home is kept clean and hygienic at all times. St Martin`s House DS0000008910.V371934.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Martin`s House DS0000008910.V371934.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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