Inspection on 20/02/07 for St Mary`s Convent & Nursing Home

This inspection was carried out on 20th February 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`s Convent & Nursing Home 06/01/06

St Mary`s Convent & Nursing Home 07/09/05

St Mary`s Convent & Nursing Home 16/02/05

St Mary`s Convent & Nursing Home 03/08/04

St Mary`s Convent & Nursing Home 09/02/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE St Mary`s Convent & Nursing Home Burlington Lane Chiswick London W4 2QE Lead Inspector Robert Bond Key Unannounced Inspection 20th February 2007 10:00 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 Mary`s Convent & Nursing Home DS0000010958.V328221.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`s Convent & Nursing Home DS0000010958.V328221.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary`s Convent & Nursing Home Address Burlington Lane Chiswick London W4 2QE 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) 020 8994 4641 020 8995 9796 st.marys.convent@ukgateway.net Society of St Margaret Ms Elizabeth Anne Smith Care Home 61 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0), Physical disability of places over 65 years of age (0) St Mary`s Convent & Nursing Home DS0000010958.V328221.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home to provide general nursing care to service users over the age of 60 Service Users to include 38 beds providing care with nursing and 23 beds providing personal care. 6th January 2006 Date of last inspection Brief Description of the Service: St Marys Convent is a listed building, situated in Chiswick, originally built in 1896. It is a care home for nursing and personal care and is registered to provide care for sixty one service users. The Registered Providers are the Anglican Sisters of the Society of St. Margaret. The home is registered as a Company limited by guarantee and is a Charitable Organisation. Major refurbishment works have taken place to replace the existing wards with single en suite bedrooms. A new kitchen, additional sitting area and dining room, a physiotherapy room, and a hairdressing room have been added to the accommodation. There is also Chapel within the building. The accommodation is situated over two floors. The ground floor accommodates thirty eight service users requiring nursing care and the first floor accommodates twenty three service users requiring personal care. There are a total of fifty seven single and two double bedrooms with en-suite facilities, which have the minimum of a toilet and wash hand basin. Some ensuite rooms have showers or baths. All bedrooms have been decorated and furnished to a high standard and there are telephone connections for private use. Portable telephones are also available. The communal areas are spacious and accessible to wheelchair users. The staff team includes a Responsible Individual, the Registered Manager, Registered Nurses and 2 Physiotherapists. Several members of the staff group are resident at the home. Fees are in the range £450 to £650 per week. The home is registered with the Registered Nursing Homes Association. St Mary`s Convent & Nursing Home DS0000010958.V328221.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a ‘key inspection’ that considered only the key National Minimum Standards (NMS) for care homes for older people. Before the inspection took place, the CSCI sent out a pre-inspection questionnaire for the Registered Manager to complete and return. Questionnaires were also sent to service users (residents), relatives, General Practitioners, health professionals, and care managers who place service users at the home. A total of 48 completed questionnaires were returned, and they demonstrated a high level of satisfaction. Quotes from some of the responses are contained within this report. On the day of the inspection, the inspector interviewed the Registered Manager and the Sister in Charge, met other staff, talked with service users, toured the premises, and examined a sample of the records maintained. The Inspector assessed the home’s performance in gaining the anticipated outcomes of 23 NMS, and found that 9 outcomes were exceeded, 13 were fully met and 1 was only partly met. This led the Inspector to make one requirement and one recommendation. The two requirements from the previous CSCI inspection report were fully complied with. On the day of the inspection, the home was fully staffed. 59 service users were present, and the home had two vacancies, one of which was in a double room. The home has a waiting list of 80 people interested in a place. No equality and diversity issues came to light. The home operates and is managed to a high standard. What the service does well: Prospective service users are provided with a good Welcome Pack. Full assessments are undertaken before service users move in, and contracts or terms and conditions are issued to all service users. Detailed and individualised care plans are prepared for each service user, who are consulted on the contents where possible, and the contents of the care plan are regularly reviewed. St Mary`s Convent & Nursing Home DS0000010958.V328221.R01.S.doc Version 5.2 Page 6 High standards of personal care and nursing care are provided. Nursing care is quality controlled using the Blue Cross mark of excellence method. Medication administration is of a high standard. A full programme of activities is provided. Independence is promoted, and service users are given the choice to socialise or not. Privacy and dignity are very well respected. Records, policies and procedures are up to date and are well kept. The food provided is of a high standard, with plenty of choice options, and served in very pleasant surroundings. The home is well maintained, clean and hygienic. It is decorated, furnished and equipped to a high standard. The home is fully staffed, to a good level, and staff members are well trained. Excellent training records are in place. All necessary recruitment checks are undertaken when new staff members are recruited. Service users assist in the recruitment process. Internal and external quality assurance measures are in place. The home has an excellent Business Plan in place. Health and Safety are given a high priority. Service users, relatives, and health professionals connected with the home all express high levels of satisfaction. The home is very well managed. What has improved since the last inspection? The management of the home has been strengthened so that each of the five units of the home now has its own manager, and the home has a deputy manager to assist the Registered Manager. Additional members of the care staff have been awarded or are undertaking NVQ awards in care. The care planning system is in the process of being computerised. The homes CSCI registration certificate is now in full view, for the benefit of visitors to the home. St Mary`s Convent & Nursing Home DS0000010958.V328221.R01.S.doc Version 5.2 Page 7 The temperatures of all refrigerators within the home are now being monitored. A second physiotherapist has been recruited and the number of exercise sessions has increased. The main dining room’s carpet has been replaced with a more suitable wood laminate floor. New table-clothes and serviettes have been purchased. Service users are now involved in the staff recruitment process. A Residents Forum has been set up. 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 Mary`s Convent & Nursing Home DS0000010958.V328221.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`s Convent & Nursing Home DS0000010958.V328221.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 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have all the information they need to make an informed choice about where to live. Each service user or their relative has been issued with a satisfactory written contract/statement of terms and conditions concerning their stay at the care home. No service user moves into the home without a full and comprehensive assessment having been undertaken. The home does not offer intermediate care. EVIDENCE: The Inspector examined the homes Welcome Pack that contained the Service Users Guide, the home’s complaints procedure, and a copy of the latest CSCI inspection report. The Welcome Pack was of a good standard. The Inspector examined two care files of service users who had recently moved into the care home. On them the Inspector found one complete initial assessment undertaken by the care home making the referral to St. Mary’s, St Mary`s Convent & Nursing Home DS0000010958.V328221.R01.S.doc Version 5.2 Page 10 and one admission application form from a self-funding applicant. Full assessments undertaken by staff from St. Mary’s before the service user was offered a place were also on file. In both cases a contract (terms and conditions) had been issued and signed by both parties. St Mary`s Convent & Nursing Home DS0000010958.V328221.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. Service Users’ health, personal and social care needs are well set out in individual plans of care. Service users health care needs are fully met. Service users are fully protected by the home’s policies and procedures for dealing with medication that exceed the NMS. Service users feel they are treated with full respect and their right to privacy is fully upheld. EVIDENCE: The Inspector case-tracked (examined in detail) two care plans that had been devised following the information gleaned from the referral information and during the home’s initial assessment process. The care plans considered every appropriate aspect, and identified needs, goals, and how to achieve them. Details of how to provide personal care and how to meet health care needs were included. Social care needs and interests are recorded. St Mary`s Convent & Nursing Home DS0000010958.V328221.R01.S.doc Version 5.2 Page 12 The care plans were seen to be reviewed at least monthly, and were signed by the service user or their next of kin. The care plans included a photograph of the service user. Service users’ weight was recorded monthly. Daily notes were well kept. The care plan format is currently a complex form that is completed in hand writing and therefore not always easily read. The Registered Manager reported that a computerised system known as Cool Blue was being introduced. Risk assessments are undertaken, signed by the service user or next of kin, and are regularly reviewed. The home employs its own nurses and physiotherapists. Other specialist health inputs such as occupational therapy, optician, dentist and chiropody are available as necessary. One service user responded in her questionnaire that the medical support provided is “exceptionally good. The doctor is very caring and goes into great detail and refers you to tests etc.”. Another service user said, however “Sometimes the doctor has been and gone before I have seen him… a lack of communication somewhere along the line.” One of three GPs who completed a questionnaire said, “The best home I have the pleasure to work with.” The Inspector examined a sample of the medication administration records, including those for controlled medication. All were in order. The Inspector also examined the medication trolleys, and storage arrangements. The Registered Manager explained that the home were considering keeping some medication in locked cabinets in some service user’s rooms. The Inspector examined the records for the return of unused medication, which were in order. Grundons waste collection company hold the contract for the collection and destruction of unused medication.. The home also has a kit for denaturing unused medication prior to the waste being taken away. . As this is an additional precautionary measure outside the NMS, it is commended. Privacy and dignity was seen to be well maintained by staff knocking on bedroom doors and treating service users with great respect. The few shared rooms are fitted with screens. One service user responded in her questionnaire that “I wish to be as independent as possible. This is stimulated by the staff’s attitude of being there when necessary”. Another service user wrote, “The home provides the right balance of shared fellowship and freedom of space – to be with others or alone as one wishes.” St Mary`s Convent & Nursing Home DS0000010958.V328221.R01.S.doc Version 5.2 Page 13 These staff attitudes are commended. St Mary`s Convent & Nursing Home DS0000010958.V328221.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 excellent. This judgement has been made using available evidence including a visit to this service. Service users are very well pleased with the variety of social, cultural and religious events and activities on offer. Service users are enabled well to maintain links with relations and the wider community. Service users are helped to a great extent in exercising choice and control over their lives. Service users say they receive a very wholesome appealing and balanced diet and it is served in very pleasant surroundings. EVIDENCE: Individual social needs and interests are recorded in the care plans. The home has a weekly activity programme, and an advertised list of future events. On the day of the inspection, a keep fit group was in full swing. The home also has its own library and its own chapel. The Registered Manager reported that attendance at services is not compulsory and the religious views of non-Anglicans are respected. Concerts are a feature of the home, and outside activities include a swimming group. Certificates are issued to service users who partake. Other activities mentioned by service users themselves include art and craft classes, reading sessions, bowls, talks, videos, visiting St Mary`s Convent & Nursing Home DS0000010958.V328221.R01.S.doc Version 5.2 Page 15 animals from a farm, and weekly mini-bus outings. The range of activities, and the use of incentives such as certificates, are both commended. The Inspector met relatives within the home, and noted from the visitors’ book the large degree of visiting that goes on. One service user told the Inspector about being taken out by her relatives. Thus community contact is well promoted. A service users wrote, “Visitors are welcomed and may stay for a meal.” A Residents Forum of service user representatives now meets quarterly to replace the former monthly residents meeting. The Registered Manager reported that service users are now involved in staff recruitment, which is commended as the practice exceeds the NMS. Autonomy and choice are thus strongly promoted within the home. Meals are served in three areas of the home, the main dining room, the small refectory, and in the day room. All three rooms are attractive places to eat. The floor of the dining room has been laid in wood laminate, which is more suitable than carpet. New table clothes and serviettes have been purchased and make the table settings very attractive. Special cutlery and crockery is provided for service users with arthritic hands. Each service user has their own serviette ring to identify where they are to sit that day. Thus service users move around and eat their meals with differing colleagues if they wish to, thus stimulating conversation. This practice should be kept under review, and the views of service users obtained. There is a good choice of meals in that there are two main courses each day and six side salads to choose from. One of the service user respondents said, “ The food is excellent, a very well balanced nutritionally satisfactory diet, plenty of variety and choice, well-cooked – delicious.” St Mary`s Convent & Nursing Home DS0000010958.V328221.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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and relatives express confidence in the complaints system. Service users are well protected from abuse. EVIDENCE: The Inspector noted that the home’s complaint’s procedure meets the NMS, and is well advertised within the care home. Every service user is issued with a copy as part of the Service Users’ Guide. Service users and relatives confirmed to the CSCI in their questionnaire responses that they knew how to make a complaint. The complaints process is issued, with the home having received and recorded four complaints since the previous CSCI inspection, three of which were from the same relative concerning the same issue. The complaints were recorded using a form for the purpose, in handwriting. As a result it was not easy for the Inspector to quickly judge exactly how well the complaint had been recorded, investigated and responded to. Therefore it is recommended that the complaints recording system is reviewed and that any reporting that is initially done in handwriting, is subsequently word processed. See Recommendation 1. No complaints have been received by the CSCI but the questionnaires contain occasional concerns. For example one respondent writes that she is not kept informed by the home about important matters affecting her relative who lives in the care home. Five respondents also expressed concern about the length of time it sometimes takes for the call bell to be answered at night. St Mary`s Convent & Nursing Home DS0000010958.V328221.R01.S.doc Version 5.2 Page 17 The home has the London Borough of Hounslow’s Adult Protection (Safeguarding Adults) policy and procedure in place. Managers within the home have been trained in the referral process for any service user who they suspect may have experienced abuse of any type. Staff members within the care home have been trained in detecting abuse by L. B. Hounslow, and further training is scheduled for March 2007. St Mary`s Convent & Nursing Home DS0000010958.V328221.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 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users live in an excellent environment that is safe and well maintained. The home is very clean, pleasant and hygienic. EVIDENCE: The Inspector toured most parts of the large building that comprises St Mary’s Convent and Nursing Home. The building has been renovated and extended over the years, to a high standard. The corridors are wide and generally well lit. Bedrooms are substantially larger than the minimum standard, and are ensuite. All but two of the bedrooms are single rooms. The rooms are furnished and decorated to a high standard. The home is excellently equipped in terms of special baths, and there are two elevators to the first floor. There is a kitchenette where service users can make their own snacks. St Mary`s Convent & Nursing Home DS0000010958.V328221.R01.S.doc Version 5.2 Page 19 There is an area where visitors can make hot drinks. The home has a hairdressing room, a physiotherapy room, and a library that contains daily newspapers. The kitchen is extremely well equipped, and is very clean. The former kitchen has become a communal area known as ‘the orangery’. The room has a tiled floor, tables to sit at whilst having a snack, and an ornamental fish tank to admire. The presence of attractive and relaxing areas such as this, is commended. The home’s sitting rooms are pleasant places. The home has an attractive and safe garden. The home is very clean and hygienic throughout, and no unpleasant smells were detected. No outstanding maintenance items were noted by the Inspector. St Mary`s Convent & Nursing Home DS0000010958.V328221.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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ needs are well met by the numbers and skill mix of staff, but there is an issue to investigate about night time response times to the call bell. Service users are in safe hands at all times as staff are well trained. Service users are well protected by the home’s good recruitment policy and practices. Staff are well trained and are competent. EVIDENCE: The Inspector received sample staff rotas in advance of the inspection, and there were sufficient staff on duty on the day of the inspection. The Inspector talked to a group of staff members as they were taking their mid-morning break. No issues were raised. The issue reported in the complaints section about call bells not being answered quickly enough at night must be investigated by management. The call bell system may be able to log how long it takes for individual calls to be answered and the bell cancelled. See Requirement 1. The home is fully staffed reported the Registered Manager. The Inspector examined the recruitment papers of two recent recruits. All appropriate checks had been undertaken. The Registered Manager reported St Mary`s Convent & Nursing Home DS0000010958.V328221.R01.S.doc Version 5.2 Page 21 that service users are involved in the staff recruitment policy. This exceeds the NMS guidance and is commended. The Inspector found that the home keep very good training records, and he saw training programmes for the home as a whole for 2006 and 2007. The Registered Manager reports that 55 of the care staff have obtained NVQ in care awards. Induction and mandatory training is provided as it should be, and staff also receive additional training in aspects such as dementia care. St Mary`s Convent & Nursing Home DS0000010958.V328221.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, 33, 35 and 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users live in a home that is managed excellently. The home is run very flexibly, and very much in the best interests of service users. Service users’ financial interests are safeguarded in that the home does not look after service users’ money. The health, safety and welfare of service users and staff are fully promoted and protected. EVIDENCE: Although the Registered Manager has a Certificate in Management Studies from the Open University, she reports that she has also commenced the Registered Managers Award (RMA), even though this additional qualification is not strictly necessary. Undertaking the RMA in these circumstances is commended. St Mary`s Convent & Nursing Home DS0000010958.V328221.R01.S.doc Version 5.2 Page 23 As evidenced by the low number of requirements made in the CSCI inspection reports for St Mary’s Convent and Nursing Home, and by the almost universally positive feedback received from service users and their relatives, the CSCI judge that the home is managed excellently. The home undertakes its own customer surveys, that lead to a summary report and the publication of a Business Plan, which is an excellent document. Internal quality audits are undertaken by the home’s own Quality Manager who uses the Blue Cross Mark of Excellence model. As this practice exceeds the NMS guidance, it is also commended. The Registered Manager reported that the home does not hold money for service users. The Inspector noted that fridge and freezer temperatures are recorded daily, and were seen to be within approved limits. The Inspector tested the homes call bell system and found it to be working, and quickly answered. The Inspector tested the hot water temperature and found it to be at a safe temperature. The Registered Manager reported that the ‘Britannia’ system is used for undertaking monthly health and safety checks of the building. St Mary`s Convent & Nursing Home DS0000010958.V328221.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 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 4 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x x x x x x 3 STAFFING Standard No Score 27 2 28 3 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 4 x 3 x x 3 St Mary`s Convent & Nursing Home DS0000010958.V328221.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP27 Regulation 18(1)(a) Requirement The registered person must take action concerning the reported delays that sometimes occur in answering the call bells at night. Timescale for action 01/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP16 Good Practice Recommendations That the complaints recording system is reviewed in order to achieve greater clarity concerning the complaint, the investigation, and the outcome, and that all recording is word processed. St Mary`s Convent & Nursing Home DS0000010958.V328221.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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`s Convent & Nursing Home DS0000010958.V328221.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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