Inspection on 24/04/07 for St Mary Magdalene Residential Unit

This inspection was carried out on 24th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Mary Magdalene Residential... 08/11/05

St Mary Magdalene Residential... 06/05/05

St Mary Magdalene Residential... 29/09/04

St Mary Magdalene Residential... 09/06/04

St Mary Magdalene Residential... 29/01/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE St Mary Magdalene Residential Unit Claremont Road Newcastle Upon Tyne Tyne & Wear NE2 4NN Lead Inspector Elaine Malloy Key Unannounced Inspection 09:15 24 and 25th April 2007 th 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 Mary Magdalene Residential Unit DS0000000458.V335170.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 Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary Magdalene Residential Unit Address Claremont Road Newcastle Upon Tyne Tyne & Wear NE2 4NN 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) 0191 2697920 0191 2697921 st.marymagdalene@btconnect.com St Mary Magdalene & Holy Jesus Trust Mrs Noreen Saxelby Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places St Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th November 2005 Brief Description of the Service: St Mary Magdalene is a care home that provides personal care for up to twenty older people. It is situated in a complex of sheltered housing that is run by the same charity and there is a shared kitchen and dining room. The home has communal lounge and dining areas. All bedrooms are single and one has an ensuite facility. There is a passenger lift and all parts of the building are accessible. A guide to the home’s services and inspection reports are readily available at the home. The current weekly fee is £373 for residents funded by the Local Authority and £425 for existing residents who are privately funded. The fee is £450 for privately funded residents admitted after 1st April 2007. St Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out by: • Looking at information received since the last inspection on 8th November 2005. • Using information from a questionnaire that the manager completed about the service. • An inspector visiting the home unannounced on 24th and 25th April 2007. • Getting the views of people who use the service and their relatives by talking to them and from surveys they completed. • Talking to the manager and other staff about the service. • Looking at records about the people who live at the home and how well their needs are met. • Looking at a range of other records that must be kept. • Checking that staff have the knowledge, skills and training to meet the needs of the people they care for. • Looking around parts of the building to make sure it is clean, safe and comfortable. • Checking what improvements had been made since the last inspection. What the service does well: Each person admitted into the home has a detailed assessment of his/her needs carried out. The information is used to plan the way in which they are assisted with health, personal and social care. Care plans are kept up to date and are recorded to a high standard of detail. This means that staff have clear guidance on the care that each person requires and how to maintain their independence. Residents feel that staff observe their rights to privacy and dignity and treat them respectfully. Medical professionals and the home’s staff provide very good support to help residents to meet their health care needs. Trained staff administer and record medication appropriately to make sure residents are protected by safe practices. Residents are consulted about, and provided with a range of one-to-one and group activities and outings for their social stimulation. Contact with family, friends and the local community is encouraged. Individuals live the lifestyle they prefer and are assisted, where necessary, to make choices and decisions in daily living. A varied and well balanced diet is offered. Residents choose meals from the menu and said they enjoy the food. St Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 6 Any complaints about the service are taken seriously and investigated promptly. Residents and their families are confident their concerns will be listened to and acted upon. The home aims to keep residents safe and has procedures and trains staff in preventing abuse of vulnerable people. Residents live in accommodation that is clean, comfortable and well maintained. Plans are being drawn up to make improvements to the building in the near future. There are good staffing arrangements to enable resident needs to be met. A thorough procedure is followed when new staff are recruited to protect residents from unsuitable people being employed. Staff are provided with a range of training that is relevant to caring for older people and many have achieved care qualifications. This enables residents to be cared for by competent staff who have the necessary skills. The manager has extensive care experience and is qualified. There are systems to get residents, relatives and staff views and improve the quality of the service. Residents and relatives are complimentary about the standard of care that the home provides. Comments included, “ They can’t do enough for me”, “I am very happy here in the home”, and “The care home takes very good care of my mother and I appreciate what they do”. Resident personal finances are held safely and proper accounts are kept. A range of health and safety checks is conducted to promote the health and safety of residents and staff. What has improved since the last inspection? What they could do better: A declaration is to be introduced into the staff recruitment process to confirm each person is physically and mentally fit to do the work. St Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 7 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 Mary Magdalene Residential Unit DS0000000458.V335170.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 Mary Magdalene Residential Unit DS0000000458.V335170.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): 3. Standard 6 is not applicable, as the home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who are considering using the service have their care needs properly assessed before they move in. This is done to make sure their needs can be met at the home. EVIDENCE: The manager has updated the home’s admission procedure, as recommended at the last inspection. This has made it clearer and includes how people being admitted for short stays have their needs assessed. The Trustees for the home have been given the procedure to discuss and approve. St Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 10 A sample of care records was examined. These showed that individuals have their care needs assessed by the manager or, in her absence by an authorised deputy, usually a team leader before admission to the home is agreed. Medical information is also requested from the person’s doctor and a check is made of the health care services he/she needs. Social Workers provide the home with assessments if a Local Authority is funding the person’s care. The same process is carried out for people who are referred to have respite care at the home. Care plans are then recorded based on the individual’s needs that are identified from assessments. Residents who completed surveys said they received enough information before moving in so they could decide if it was the right place for them. A lady who moved into the home in recent months said she has settled well and confirmed her needs were assessed before admission. A lady staying temporarily at the home had her assessment carried out whilst she was in hospital. She said she was grateful to have respite care as she is unable to look after herself at present, and is hoping to return her home on the complex. St Mary Magdalene Residential Unit DS0000000458.V335170.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 and 10. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents have high standard care plans that show how they are helped to meet their health, personal and social care needs and remain independent. Residents are very well supported in meeting their individual health care needs and have access to a full range of medical services. Residents are protected by a safe medication system. Residents are treated with respect and staff observe their rights to privacy and dignity. St Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 12 EVIDENCE: Residents and people staying for respite care have recorded care plans based on their needs. The care plans examined were detailed and specific to the individual’s requirements and preferences. They addressed physical care, personal hygiene, mental health, medical conditions, night care, and social and spiritual needs. The plans showed the care and support staff will provide and what people can do for themselves. Where risks to the person are identified, the plans include how these will be managed or minimised. Day and night reports are recorded that cross-reference to care plans and provide information to evaluate the plans. Staff evaluate care plans every month, or more often if needed, to keep an on-going account of how the plan is working. For example, the records demonstrated how a lady was making progress in rebuilding her confidence and becoming more independent. Residents and their relatives are invited to attend a six monthly review to discuss his/her care. These meetings were well recorded and showed what was discussed, any decisions made and the action that would be taken as a result. Residents usually keep their own doctor and seven local practices are used. The District Nursing Service currently provides input twice weekly. The District Nurse visited during the inspection. A carer was allocated to accompany her and make notes on treatment and advice so this could be recorded in individual’s care records. This is good practice. There are arrangements for an optician, dentist and podiatrist to make home visits. All contact with health care professionals is well recorded. If a resident is admitted to hospital staff keep a check on their progress. They also make sure he/she is well enough to return to the home and that the right aids and equipment are provided before they are discharged. Residents said they “always” or “usually” receive the medical support they need. Each person has his/her moving and handling, nutrition, and continence needs assessed. There were some very good examples of care plans relating to health needs and specific medical conditions. These included a comprehensive plan for a lady with mobility and moving and handling needs that incorporated risk of falls and a daily exercise plan. This was being monitored closely and staff evaluate the plan on a daily basis. The lady confirmed that her health needs were being well attended to. Another example showed care plans were recently put in place for a lady who is becoming physically frailer. One plan addressed recent weight loss and staff keep and monitor records of her food and fluid intake. She also had a plan for deteriorating sight that included aids to maintain her independence and referral to a specialist sensory team. St Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 13 Residents are asked whether they wish to take responsibility for their medication, and if so an assessment of the risks is completed. No residents currently keep their own prescribed medication. Senior staff and some carers have completed ‘Safe Handling of Medication’ training and they administer medication. Resident photographs are kept on the medication sleeves for identification purposes. A sample of medication records was examined. These were appropriately completed and the previous requirement to improve recordings was met. All residents have a single bedroom with telephone and call system. Residents can also have a pendant to wear to summon help that is linked to the telephone system. All personal care and medical examination/treatment is carried out in private. Each person is asked the name they wish to be addressed by and their preference for male/female carers, and this is recorded. Mail is given unopened directly to residents. Staff will provide support with dealing with correspondence if needed. The home has dedicated laundry staff. Name labels are used to identify individuals clothing to make sure it is returned to the owner. Residents said that staff treat them respectfully. Some people told the inspector that staff always knock at doors and do not enter their bedrooms without permission. Residents are offered keys to their bedroom. One lady said she appreciated the fact that staff help her with personal care in a dignified manner. St Mary Magdalene Residential Unit DS0000000458.V335170.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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are well supported to live their preferred lifestyle and are offered a variety of activities to meet their social needs. Residents maintain contact with their family and friends and are supported to make use of the local community. Residents are encouraged to make choices and decisions and keep control over their lives. Residents are offered a balanced diet with choice of meals and enjoy the food. St Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 15 EVIDENCE: The home has a policy about residents leading their preferred lifestyle. Each person has a social assessment completed that gives information on his/her background, lifestyle, routines and interests. The information is used to record individual social care plans. The manager said residents are free to pursue their own interests and choose whether they wish to participate in activities provided by the home. Wherever possible carers provide one-to-one time and accompany individuals to go out. Residents confirmed this to the inspector. Residents are asked about social activities at Resident Meetings. The minutes of the latest meeting showed residents suggestions for destinations for outings. A monthly newsletter is published that gives details of outings and activities taking place in the home and within the complex. Records are kept in a social diary of activities that take place and those residents who have taken part. Regular activities include a history group, art and computer classes, flower arranging, quiz, bingo, darts, snooker, bowls, knitting group, and line dancing. Visiting entertainers are organised. There had been outings to the Quayside, Metro Centre and a Historical Society Meeting. Further outings were being planned for the summer months. The majority of residents who completed surveys said there was usually activities arranged by the home that they could take part in. Residents told the inspector there are social activities available and they choose which ones to join in. Some residents make use of local facilities, for example the newsagents, hairdresser, pubs, Exhibition Park and Town Moor. The home has an open visiting policy. Residents choose whom they wish to see and to receive visitors in their bedroom or communal areas. Contact with family and friends is supported through visits, telephone contact and letters/cards. Relative involvement is welcomed and they are invited to take part in resident meetings and individual’s care reviews. A ‘Family Forum’ takes place twice yearly when two relatives of former residents visit, talk with residents and hold a meeting. The Trustees for the home visit the home regularly and talk with individuals. Relatives/visitors said the home helps their relative/friend to keep in touch with them. They said they are always kept up to date with important issues affecting their relative/friend. St Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 16 The home has a policy on maintaining personal autonomy and exercising choice. Residents choose how to personalise their bedroom and agree the extent of possessions and furnishings to bring into the home before admission. Each person is allocated a member of staff as their named ‘key worker’. The latest newsletter reminded residents of who their worker is and that they are responsible for care plans, presentation of rooms, personal shopping and labelling clothing. Residents are involved throughout the process of assessing their needs and risks, and wherever possible sign to agree their care plans. Comments from residents and relatives are recorded in the minutes of individual’s care review meetings. A policy is in place that verifies residents have access to their personal records. Residents are encouraged to manage their financial affairs. The majority continue to do so, and others are assisted by relatives/solicitors. The home’s management does not take responsibility for resident finances, except for holding cash for personal spending in the safe. Some staff have undertaken training on equality and diversity to help them recognise individuals diverse needs. Relatives said the service supports people to live the life they choose and meets the different needs of people. Nutritional needs are assessed and resident weights are monitored. No residents currently require special diets for medical or cultural reasons. Independent eating is encouraged, with use of aids if needed, and one lady uses a plate-guard and a lidded cup. The manager said she was looking towards improving mealtime practices by reintroducing tureens for residents to serve themselves. Some residents told the inspector they would prefer this. She was also looking at kitchen staff helping to serve food, and care staff sitting with residents during meals. Meal times are flexible and residents can choose when and where to eat. They can take meals in the dining rooms in the home, the main dining area on the complex, or in their bedroom. Choice of starter, main meal and dessert is offered at lunch. There is a varied menu and alternatives can be requested. Residents are asked their preference for meals one week in advance. Some people told the inspector they forget the meals they have selected, but that menus are displayed and they can change their mind on the day. Special occasions and seasonal events are catered for. St Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 17 The inspector dined with residents at lunch. The tables were nicely set and condiments were available. Staff were kind and efficient and served the meal at each person’s pace. A choice of hot and cold drinks were served. Residents told the inspector they like the food and are offered choice of meals. Some people said that portion sizes are too large and they do not like to see food wasted. Each resident who completed a survey also said they always like the meals. Comments included, “Meals are always lovely but too substantial”, “Very nice but portions too big”, and “More than enough to eat”. The issue of portion sizes has been raised with catering staff before and the manager said she would discuss this with them again. St Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 18 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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Any concerns that residents or relatives raise are taken seriously. Prompt and appropriate action is taken when a complaint is received. The home keeps residents safe by having thorough procedures and training staff in preventing abuse. EVIDENCE: A book for comments and compliments is kept, with thank you cards and letters. Many entries were positive comments about the service from relatives and people who had stayed for respite care. The complaints procedure is included in the home’s guide to services that is given to all residents. The Commission has not received any concerns or complaints about the home since the last inspection. Appropriate records were kept of complaints made directly to the home. These showed the nature of complaint, prompt investigation and details of any further action taken. St Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 19 Residents spoken with had a good understanding of how to make a complaint and indicated they would have no hesitation in doing so. Some residents commented that they were confident the manager would deal with anything they were unhappy about. The majority of residents and relatives who completed surveys said they would know how to make a complaint. One resident and one relative did not know. Each relative said they had received an appropriate response if they had raised concerns. The home has a range of policies and procedures on recognising the signs of, and preventing abuse, protecting vulnerable adults (POVA), and ‘whistle blowing’ (informing on bad practice). No allegations of abuse have been made. The manager understands her role to report any allegations to the relevant authorities. Staff are provided with training on protecting residents from abuse. Courses were being arranged for newer members of staff. Senior staff have had ‘alerter’ training to make sure they know what to do in the event of an allegation being reported. Residents told the inspector that staff treat them very well and they feel safe living at the home. St Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 20 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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a clean, safe and well-maintained building. EVIDENCE: Architects have recently visited the home with a view to a drawing up plans for a proposed refurbishment. In the period since the last inspection no redecoration or renewal of carpets has been needed. The purchase of new bed linen, curtains, lamps and bedside cabinets will be considered when the building is upgraded. St Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 21 All parts of the building seen were clean, nicely decorated and furnished and suitably equipped. Maintenance and repairs are carried out as required. Two handymen are employed for the complex. Residents said they are happy with their comfortable accommodation. One lady commented on the lovely view from her room. All residents said the home is always fresh and clean. There are policies and procedures on hygiene and control of infection. Staff are provided with infection control training. A Team Leader is the designated link person for infection control and attends meetings with the local Health Protection Agency. Disposable gloves and aprons are supplied for staff use and alginate bags are available for dealing with soiled items. There are suitable hand-washing facilities with liquid soap and paper hand towels. Arrangements are in place to dispose of clinical waste. It is likely that the proposed refurbishment will include additional en-suites in bedrooms. St Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 22 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides good levels of skilled care staff to meet the needs of the residents. A high ratio of workers has completed or is studying for nationally recognised care qualifications. Thorough procedures are used to recruit new staff and to make sure residents are protected. Staff receive a wide range of training that is relevant to caring for older peoples needs. EVIDENCE: At the time of the inspection there was 15 residents, and two residents were in hospital. There are four carers on duty from 8.00am to 2.00pm then three carers until 8.30pm and two carers at night. All care staff employed at the home are over 18 years of age and staff left in charge are over 21. Four ‘bank’ carers are employed to cover for absence for staff sick leave and holidays. A good level of domestic/laundry and catering staff hours are provided. St Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 23 The majority of residents who completed surveys said they always receive the care and support they need. They said staff listen and act on what they say, and are “always” or “usually” available when they need them. Residents praised staff to the inspector. Comments included “ They can’t do enough for me” and “The girls are lovely”. Relatives said the home meets the needs of their relative/friend, gives the support/care they expected and that staff have the right skills and experience. At the last inspection there was an outstanding requirement. This was that the homes staff must not be required to take emergency or other calls from service users receiving community care on the complex. The General Manager has given her assurance that this will be resolved in the near future subject to changes to the telephone system when the building is upgraded. Emergency calls between 8.00pm and 8am only will be transferred to the care home. At the previous inspection it was recommended rotas be revised to include the manager’s supernumerary hours. These are the hours that she has to carry out her management duties. The manager and general manager have reviewed Mrs Saxelby’s supernumerary time. She has 24 hours weekly and during this time the team leader or a senior care assistant supervises the day-to-day operation of the home. 14 of the 22 care and senior staff have achieved National Vocational Qualifications (NVQ) in care at Level 2 or above. All seniors have completed NVQ Level 3 training and are considering progressing to Level 4. Four carers are studying for NVQ Level 2, and a further two are being enrolled on the course. There are currently no staff vacancies. A sample of staff recruitment files was examined. A checklist is used to make sure all necessary information is in place. All staff are recruited subject to Criminal Records Bureau (CRB) checks being carried out. The files contained photograph and proof of identification, application form, references from suitable sources, and health questionnaire. Deficits to the recruitment process had been addressed, as previously required. A declaration that confirms the person is physically and mentally fit to do the work is to be introduced. St Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 24 The home has good links to a range of training providers. Certificates and records of training are kept for each staff member. In the past year staff have received training in the following areas: internal and external induction training for new staff, National Vocational Qualifications, safe working practices, safeguarding vulnerable adults, health and safety, medication, catheter care, and use of continence aids. The manager and two seniors are studying for qualifications in Equality and Diversity, and exploring prejudice and discrimination. A variety of in-house training is also provided that is based on induction standards and the home’s policies and procedures. This training is carried out using different methods such as practical demonstrations, role-play and questionnaires. Staff confirmed that they receive a good level of training. St Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 25 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, 33, 25 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a home that is well managed by an experienced and qualified manager. The home has developed systems to monitor the quality of the service provided. This makes sure that the home is run in the best interests of residents. Residents have their personal finances safeguarded. The welfare of residents and staff is promoted and there are good health and safety systems. St Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 26 EVIDENCE: Mrs Noreen Saxelby is the home’s Registered Manager and has been in post since 2000. She has 21 years of experience in care work, most of which has been in a senior/management capacity. Mrs Saxelby has completed care and management qualifications including the Registered Manager Award. The manager is accountable to the General Manager and a Board of Trustees. An annual plan for monitoring the quality of the service has been introduced, as recommended at the last inspection. Methods used include getting the views of residents and relatives through meetings and family forums, and individual care reviews. Surveys had been given to residents earlier this year. The results were collated and feedback was given at a resident meeting. A range of audits is carried out to check the home’s systems and records. Staff are trained to meet resident needs, are individually supervised and staff meetings are held. The Trustees and General Manager have regular contact and carry out monthly ‘conduct of home’ visits and prepare reports. The home’s policies and procedures are linked to national standards for care homes for older people. Residents spoke positively about the standard of the service and told the inspector they were well cared for and supported. Comments included, “I am very happy here in the home” and “The staff look after all my needs”. Relatives who completed surveys were asked what they feel the home does well. They said, “All the important requirements”, “Everything”, “The care home takes very good care of my mother and I appreciate what they do”, “General help of attending to persons needs”. Relatives were also asked how they think the home can improve. None gave any suggestions and one person said, “ Seems to be very well able to cater for most types of care and well-being for the residents in the care home”. Another relative commented, “My aunt resides very happily in this well managed home. The staff are very good, as are the meals, and her friends from the nearby bungalows visit her from time to time. It is an ideal situation, she is looked after very well so we have no complaints”. Residents have individual care plans for management of finances, where this is applicable. Cash can be held in the home’s safe for personal spending. Records are kept of each person’s account. A sample of personal finances records was examined. Transactions are appropriately recorded and have two signatures for each entry. Where possible the resident or their relative signs the record. Receipts are obtained for purchases. Weekly checks of balances and cash are carried out. St Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 27 The home has a health and safety policy and range of associated procedures. Staff are provided with training in health and safety and safe working practices (fire safety, moving and handling, first aid, food hygiene, and infection control). Thorough audits are carried out to check compliance with health and safety requirements. These cover policies/procedures, safe working practices, passenger lift, C.O.S.H.H (control of substances hazardous to health), clinical waste, bodily fluid spillage, soiled laundry, medicines, smoking, violence at work, outdoor safety, gas safety, equipment safety, laundry safety, work and living environment, and general housekeeping. Servicing and maintenance agreements are in place for facilities and equipment. Risks in the environment and working practices are assessed. Individual resident’s risk-taking and management of assessed risks is documented in personal care records. All fire safety checks, tests and instructions to staff are conducted at the required frequency and recorded. Accident reporting was suitably recorded and includes details of any treatment provided and/or referral to District Nurse/ GP/hospital. St Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 28 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 St Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 29 NO 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP29 Good Practice Recommendations A declaration that confirms each staff member is physically and mentally fit to do the work should be introduced. St Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Mary Magdalene Residential Unit DS0000000458.V335170.R01.S.doc Version 5.2 Page 31 - 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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