CARE HOMES FOR OLDER PEOPLE
St Marys Haven St Marys Street Penzance Cornwall TR18 2DH Lead Inspector
Paul Freeman Key Unannounced Inspection 23rd July 2007 10:30 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 Marys Haven DS0000008905.V342707.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 Marys Haven DS0000008905.V342707.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service St Marys Haven Address St Marys Street Penzance Cornwall TR18 2DH 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) 01736 368585 F/P 01736 368585 mountthehaven@hotmail.com The Presentation Sisters vacant post Care Home 26 Category(ies) of Dementia - over 65 years of age (3), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (3), Old age, not falling within any other category (26) St Marys Haven DS0000008905.V342707.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. Service users to include up to 26 adults of old age (OP) Service users to include up to 3 adults aged over 65 with dementia (DE[E]) Service users to include up to 3 adults aged over 65 with a mental illness (MD[E]) Total number of service users not to exceed a maximum of 26 Date of last inspection 25th September 2006 Brief Description of the Service: St Marys Haven is a residential care home registered to accommodate twentyseven residents over sixty-five years of age. The home is also registered to accommodate three older people who experience dementia. The home is run by the Presentation Sisters of Penzance and Sanctuary Housing Association owns the building. Within the grounds is another registered home for nine residents, a day centre for up to fifty older people as well as a number of flats. St Marys Haven is an inter-denominational home working within Christian principals and opportunities are provided for regular Christian services. Other denominations are also welcome at the home. St Marys Haven is located near the town centre of Penzance and has access to local amenities with good transport links. The home is furnished and maintained to a good standard and is accessible for people who experience disabilities. A passenger lift is also provided at the home to allow easy access throughout. Communal space is situated on the ground and first floors. There are twenty-one single rooms and three shared rooms and a high percentage of the bedrooms have en-suite facilities and been personalised by the occupants. Currently the registered managers post is vacant but the providers have a responsible individual in place to act on their behalf in regard to the operation of the care home. St Marys Haven DS0000008905.V342707.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. A planned unannounced key inspection took place on 23 July 2007 and 24 July 2007. The purpose of the inspection was to consider the work that had been undertaken on the requirements and recommendations set at the last inspection on 8 February 2007 and to inspect other core standards. Therefore some of the key standards considered included assessment of resident’s needs, care planning, staffing arrangements and safe working practises. The manager, residents and staff were consulted about the services and facilities provided. The environment, records and documents were also considered. Written information from the providers about the services and facilities provided was also taken into account. The current registered management arrangements at the home are temporary and the post has been vacant for over fourteen months. The Commission are very concerned about the situation and the registered providers failure to recruit to this key management post. The vacancy also results in the providers failing to comply with the Care Home regulations. The Commission are pursuing areas of non-compliance with the providers as a matter of urgency. What the service does well:
Each prospective resident is assessed so the providers have a clear picture of the individuals’ needs, preferences and choices. Residents are invited to participate in the assessment. The view of relatives or representatives and professional involved with the person are also taken into account. Each resident also has a care plan that describes their needs and summarises the care and support required. The providers have recently introduced a new format for recording the plans that provides staff with better information and guidance. Residents are positive about the care and support they receive and said they were always treated with dignity and respect. Good arrangements are in place to meet residents’ health needs and medical services are promptly accessed. Trained staff administers medicines safely and residents are able to administer their own medication when it is safe to do so. St Marys Haven DS0000008905.V342707.R01.S.doc Version 5.2 Page 6 Residents have opportunities to experience a varied and stimulating life style and are able to participate in a range of activities that are provided at the home. Residents spiritual needs are also well catered for. Residents said they are able to decide upon their own patterns of daily living and were satisfied about the arrangements in place. A varied and nutritional menu is in place that reflects the residents needs, preferences and choices and promote their health. Positive arrangements are in place to deal with any concerns or complaints residents may have and to protect residents from abuse. Residents said there are no barriers to raising any issues or concerns and are confidant these will be dealt with in an efficient and satisfactory manner. The home is maintained to a high standard and the furniture, furnishings and fitting are domestic in nature wherever possible. The layout of the home is satisfactory, generally accessible and comfortable. The home is regularly maintained and a programme of redecoration is in place. Residents said that any faults that occur are dealt with promptly and were very complementary about the standard of work and efficiency of the maintenance staff employed at the home. Residents said they were very satisfied with the facilities provided and all were very pleased about their individual bedrooms that are also maintained to a good standard and many have been personalised by the occupant. Residents stated they good standards of hygiene and cleanliness are maintained at all times. Residents were very satisfied with the manner in which the staff undertake their duties and found staff to be responsive, reliable and efficient. Residents said they were able to direct their own care and it is clearly apparent that positive trusting relationships have been established. The staff are suitably trained and new staff members undertake an induction programme to make sure they are able to provide the care and support required safely. The providers have appointed an interim manager to run the care home until a Registered manager has been recruited. One of the Trustees has also been appointed to act as the responsible individual for the care home. In addition an independent person has been put in place to meet the requirements of regulation 26. The appointed person makes regular unannounced visits to the care home to consider the standards of the services and facilities provided. There are also a number of policies and procedures in place to promote safe working practices and a safe environment for the residents and staff. In
St Marys Haven DS0000008905.V342707.R01.S.doc Version 5.2 Page 7 addition risk assessment and risk management arrangements are in place to safeguard residents and staff. What has improved since the last inspection? What they could do better:
There continues to be occasions where more detailed information is required in the providers’ assessments of needs and the residents care plans. This will make sure the provider have a clear picture of the care and support required and the staff are provided with quality information. The care plans also need to be comprehensively reviewed on a regular basis and good records about the conclusions of the review must be in place. This will make sure that staff are provided with up to date information. The providers need to continue to develop the recreational opportunities available at the care home and in the local community. This will further improve the residents’ opportunities to vary their lifestyles. Residents should also be able to make a direct choice about the meals they wish to have each day. Improved arrangements are necessary to make sure the residents have more control over this aspect of their daily lives. The providers must make sure the environment and particularly the bathrooms are not cluttered as this could become hazardous for residents. The providers need to comprehensively review the staffing arrangements to make sure that sufficient staff are on duty each day and night. This review is required given the increasing levels of the care and support required by residents combined with the residents views that more staff are required at certain times each day. The failure of the providers to regularise the management arrangements is of concern and results in regulatory breeches. This is a matter of concern the Commission are actively pursuing with the providers to achieve a resolution at the earliest opportunity. St Marys Haven DS0000008905.V342707.R01.S.doc Version 5.2 Page 8 The providers also need to improve and develop their quality assurance measures to make sure a reliable system is in place to evaluate the services and facilities provided. The risk assessment and risk management arrangements and the fire safety and fire precaution measures require improvement in order that residents can be safeguarded. 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 Marys Haven DS0000008905.V342707.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Marys Haven DS0000008905.V342707.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 3 and 6. Quality in this outcome area is adequate. Prospective residents are assessed so the providers can be satisfied the facilities and services are suitable to meet the prospective residents needs, preferences and choices. The assessments need to be more detailed to make sure the providers have a comprehensive picture of the care and support required. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each prospective resident needs is assessed to make sure the services and facilities are suitable to meet the needs of the person concerned. The prospective resident is invited to participate in the assessment and their
St Marys Haven DS0000008905.V342707.R01.S.doc Version 5.2 Page 11 relatives or representatives are also consulted. The views of professionals involved with the individual are also taken into account. The assessments summarise the individual’s needs and indicate any individual choices or preferences. In certain instances there continues to be insufficient detail and information to make sure a comprehensive picture of the care and support required is in place. This also impacts upon the providers’ ability to be satisfied the services and facilities are suitable to meet the needs, preferences and choices of the person concerned. Although the quality of the assessments continue to improve the lack of detail negatively impacts upon the providers’ ability to produce a detailed and comprehensive care plan. The providers do not offer a dedicated rehabilitation or intermediate care service. Every reasonable is however taken to support residents to be as independent as possible. St Marys Haven DS0000008905.V342707.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 7, 8, 9 and 10. Quality in this outcome area is adequate. The care plans continue to improve but require more information to make sure there are clear statements about the care and support required and that residents are safeguarded. Good arrangements are in place to promote residents health and access medical services when required. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each resident has a care plan that summarises their needs and provides staff with information, guidance and direction about the care and support required. The providers have continued to improve the care planning arrangements in
St Marys Haven DS0000008905.V342707.R01.S.doc Version 5.2 Page 13 order that staff can be provided with more detailed information that safeguards health and promotes well-being. It is clear the revised care planning arrangements are a positive improvement but there still continued to be occasions where the plans are not sufficiently detailed or provide adequate guidance. The care plans are regularly reviewed in order that an up date picture of residents’ needs, preferences and choices is in place. However a number of residents the Inspector consulted were able to identify improvements regarding the care provided that did not appear to have been picked up at reviews. Residents said they were very satisfied with the care and support they received and stated that good standards of care and support were provided at all times. Residents also stated staff treated them with dignity and respect at all times. It is evident that positive and trusting relationships have been established between residents and staff. Good standards are maintained in meeting residents’ health needs and medical services are promptly accessed when required. Residents said there health needs were well catered for and there was no delay in accessing services when needed. Satisfactory and secure arrangements are in place to store and administer medicines safely. Where required medicines are stored in a secure refrigerator. Residents are able to administer their own medication when it is safe to do so but where staff assist suitable records are maintained. The staff administering medication has been appropriately trained and a suitable policy and procedure to guide and direct the staff has been established. Medicines that are no longer required are safely disposed of and appropriate records are in place. St Marys Haven DS0000008905.V342707.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): The standards considered were 12, 13, 14 and 15. Quality in this outcome area is good. Residents experience a varied and stimulating life style and are able to determine their patterns of daily living. The providers continue to improve and develop the recreational and social opportunities available to maximise residents’ stimulation. Flexible visiting arrangements are in place and a varied menu is provided that promotes the residents health. The providers can improve and develop the residents opportunities to choose the food they have at each mealtime. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents said they were satisfied with the lifestyles they experienced and were able to decide upon their own patterns of daily living. A range of activities is provided each week for the residents who wish to participate but some of the residents choose to make their own arrangements. The range of activities
St Marys Haven DS0000008905.V342707.R01.S.doc Version 5.2 Page 15 has continued to increase but is clear some of the residents still require a more varied programme. Residents also have the opportunity to attend the Day Centre that is part of the complex. However a number of residents wish to participate in different types of activities at the care home and in the local community. This also highlights the importance of good assessments of need and care planning arrangements. There are no barriers to residents accessing the local community when it is safe to do so. Community groups also attend the care home on occasions to entertain the residents. Residents spiritual needs are also well catered for. Visiting arrangements are flexible and visitors said the staff always provided a warm welcome. Residents are also able to decide where they meet with their visitors. A varied and nutritional menu is in place that reflects the residents’ needs, preferences and choices. However there is only one main meal provided each day. The kitchen staff will provide an alternative meal if this is required. The alternative meals are therefore provided on the basis of the kitchen staff knowledge of an individual’s preference and choice. However this prevents the residents from making an informed choice about the meals they want each day. The providers should work towards residents making a choice about the food they have at each mealtime. The kitchen is suitably equipped and the equipment and services are regularly serviced and maintained. The kitchen staff is appropriately trained and satisfactory health and safety practises are in place. Residents said they were very satisfied with the food provided. The kitchen staff are also in the process of reviewing the menu with the residents and also consult with residents about their preferences and choices when they first move to the care home. St Marys Haven DS0000008905.V342707.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): The standards considered were 16 and 18. Quality in this outcome area is good. Positive arrangements are in place to protect residents from abuse and respond to any complaints or concerns. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A satisfactory policy and procedure for dealing with complaints is in place. The providers or the Commission has received no complaints since the last inspection on 8 February 2007. Residents said there are no barriers to raising any issues, concerns or complaints and were confidant that any issues will be dealt with efficiently and in a satisfactory manner. Satisfactory arrangements have also been established to protect residents from abuse and a suitable policy and procedure is in place to guide and direct staff if any concerns arise. Any allegations are reported to the appropriate authorities and where appropriate a formal investigation takes place. St Marys Haven DS0000008905.V342707.R01.S.doc Version 5.2 Page 17 Suitable whistle blowing arrangements are in place for staff and this makes sure that staff can report any concerns to a third party if they feel unable to raise the matter with the providers. This provides further protection for the residents. St Marys Haven DS0000008905.V342707.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): The standards considered were 19 and 26. Quality in this outcome area is good. A good standard of accommodation is provided that is homely and comfortable for residents. High standards of cleanliness and hygiene are in place at all times which promote residents’ health and welfare. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A smaller registered care home and a day centre for older people are also located on the same site. The three facilities share a garden but this has limited access given the steps that lead to this area. The providers have improved the courtyard arrangements in order that residents can sit outside.
St Marys Haven DS0000008905.V342707.R01.S.doc Version 5.2 Page 19 Limited car parking facilities are also provided and visitors are often required to park outside the facilities. The home is situated close to the centre of Penzance. Therefore a wide range of shops, amenities and services are nearby. The home is maintained to a high standard and the furniture, furnishings and fitting are domestic in nature. The layout of the home is satisfactory, generally accessible and comfortable. The home is regularly maintained and a programme of redecoration is in place. Residents said that any faults that occur are dealt with promptly and were very complementary about the standard of work and efficiency of the maintenance staff employed at the home. Residents said they were very satisfied with the facilities provided and all were very pleased about their individual bedrooms that are also maintained to a good standard. Many have been personalised by the occupant. There is also a range of disability equipment in order that residents’ independence is promoted. The equipment also promotes safe working practises and the residents’ health and well being. Individual residents are also provided with suitable disability equipment when required and following a specialist assessment. Residents were also very satisfied with the standard of hygiene and cleanliness that is maintained. A dedicated house keeping staff is employed who clearly work to high standards and maintain a positive environment that promotes residents health. The providers need to make sure the environment does not become cluttered and therefore a potential hazard to residents. In certain bathrooms there were a number of pieces of equipment that restricted access and made the room look untidy. In addition there were a range of unnamed toiletries that had been left in bathrooms. This is not an acceptable practise and also gave an impression of untidiness. St Marys Haven DS0000008905.V342707.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): The standards considered were 27, 28, 29 and 30. Quality in this outcome area is adequate. The providers need to take steps to make sure sufficient numbers of staff are on duty each day and night to safeguard residents and provide the care and support required. The recruitment, selection and vetting arrangements have improved and good arrangements are in place that protect residents. Staff are provided with regular opportunities to participate in training to make sure their skills and knowledge are up to date. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are care staff on duty during waking hours and each night. In addition housekeeping, maintenance and catering staff are also on duty throughout each week. The providers have attempted to set the staff levels according to the individual needs of residents and by peak times throughout the day. St Marys Haven DS0000008905.V342707.R01.S.doc Version 5.2 Page 21 Some of the residents consider there is insufficient staff on duty staff during waking hours and commented there is often a delay when assistance is required. The staff also said there were times when additional assistance is required. The staff said the more complex needs of residents have not been accurately reflected in the current staffing arrangements. The Inspector also noted there were regular occasions throughout the day when staff were not in the vicinity of the upstairs lounge. Many of the residents who use this room are clearly vulnerable or frail. The manager also said that a good proportion of residents choose to attend the day centre and this had been reflected in the staffing arrangements. However there continues to be regular occasions when staff are required to provide care and support during the time residents attend the day centre. Furthermore no additional staffing resources are put in place when residents return form the day centre or at weekends. The staffing levels and staff deployment arrangements needs to be carefully considered and reviewed to make sure that sufficient staff are employed at all times. Two waking night staff is on duty overnight and reliable on call arrangements are in place if assistance is required. Residents said they were very satisfied with the care and support they receive and found the staff to be reliable, flexible and responsive to any requests they made. It is also evident that positive and trusting relationships have been established between staff and residents. Residents also described the home as relaxed and cheerful and attribute these qualities principally to the staff and the manner in which they undertake their duties and responsibilities. The staff members therefore have a wide range of skills and abilities to meet the needs of residents. Staff said the home was an enjoyable place to work and a good spirit of cooperation and teamwork was in place. The recruitment, selection and vetting arrangements meet the required regulatory standards and make sure that residents are protected. Each new staff member also undertakes an induction programme that reflects the standards set by Skills for Care. Recently appointed staff were positive about the induction arrangements. Staff are provided with regular training opportunities to make sure their skills and knowledge are up to date. In addition a good percentage of the staff group hold NVQ 2 qualification and some staff have obtained NVQ 3. Good support and supervision arrangements are also in place and staff said that assistance, guidance and support were available when required. St Marys Haven DS0000008905.V342707.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): The standards considered were 31, 33, and 38. Quality in this outcome area is poor. The Registered manager post is vacant and an interim manager is currently in post. The current arrangements are not satisfactory and it is of concern the position has not been regularised by the providers. This matter is being actively pursued with the provider to make sure a resolution is reached expediently. The quality assurance measures also require improvement so that the providers have reliable feedback about the quality of the services and facilities provided. The arrangements to promote safe working practices and good fire safety and precaution arrangements also require improvement in order that residents are safeguarded. Satisfactory arrangements are in place to provide a safe environment for residents and staff. The arrangements require more regular review to make
St Marys Haven DS0000008905.V342707.R01.S.doc Version 5.2 Page 23 sure every reasonable step is taken to safeguard residents and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manger’s post is currently vacant but a manager has been appointed in the interim while the providers recruit to the vacant post. It of concern that the post has been vacant for over a year and progress to appoint a manager and therefore comply with the regulations appears to have been painfully slow. This is not an acceptable situation and the Commission are actively addressing the areas of non-compliance with the providers directly. The provider has appointed a responsible individual who is responsible for supervising the management of the care home. An external person has also been appointed by the providers to undertake the duties prescribed in regulation 26 of the Care Homes Regulations 2001. The post holder makes unannounced visits to the home on a monthly basis and provides a detailed written report of their findings and any action that is required to promote good practise and comply with the regulations. The providers make efforts to consult with residents, staff, relatives or representatives and professionals about the services and facilities provided on an annual basis. The absence of a manager has resulted in delays to the annual quality review cycle. This has therefore placed limitations on the providers obtaining a clear picture of the quality of the service and facilities provided. A range of policies and procedures are in place to promote safe working practices. Where any situations arises that could compromise the health or safety of residents or staff it is the policy that a risk assessment takes place. However there are occasion when the risk assessment or risk management plans do not provide adequate detail and information. This could result in compromising the health safety and wellbeing of residents, staff and visitors. The Fire Officer found areas of non-compliance regarding the fire safety and precaution arrangements following an inspection visit in November 2006. It is of concern the providers have not yet fully complied with the fire officer’s requirements. This also could compromise the health, safety and wellbeing of residents, staff and visitors. St Marys Haven DS0000008905.V342707.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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X X X X 2 St Marys Haven DS0000008905.V342707.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 OP3 Regulation 14(1)(c) Requirement Assessments should be more detailed in order that residents’ needs, preferences and choices are fully taken into account. A written care plan must be in place that details how the services users’ needs in respect of their health and welfare are to be met. Timescale for action 30/10/07 2. OP7 15(1) 30/11/07 3. OP7 15(2)(b) Comprehensive reviews of each resident’s care plan must take place each month and the conclusion must be clearly recorded. Sufficient numbers of suitably qualified staff must be on for the health and welfare of service users. 30/10/07 4. OP27 18(1)(a) 30/09/07 St Marys Haven DS0000008905.V342707.R01.S.doc Version 5.2 Page 26 5. OP31 8(1)(a)9( 1-2)Sch 2 The providers must appoint a suitably qualified Registered Manager to run the home. (This requirement is renotified from 28/02/07 for the second time) The registered manager at the home must hold the registered managers award. (This requirement is renotified from 28/02/07) 30/09/07 6. OP31 9(2)(b)(i) 30/09/07 7. OP33 24(1)(5) 8. OP38 The registered person must establish and maintain a system for evaluating the quality of the services provided at the care home. 13(4)(a-c) Individual service users risk assessments must take place when any situation potentially compromises the heath, welfare and fitness of service users. Risk management plans must be put in place when any situations of unreasonable risks arise. The plans must provide sufficient detail to inform, guide and direct staff about the action required. The arrangements regarding fire detection, prevention and staff training must comply with the fire regulations and safeguard service users. (This requirement is renotified from 30/03/07) 30/12/07 30/09/07 9. OP38 13(4) (ac) 30/09/07 10. OP38 23(4)(ae) 30/09/07 St Marys Haven DS0000008905.V342707.R01.S.doc Version 5.2 Page 27 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. 2. Refer to Standard OP12 OP15 Good Practice Recommendations Service users should be offered a wider range of social, recreational and leisure opportunities that reflect their interests and hobbies. Service users should be able to make a direct choice about the food they take at each mealtime. St Marys Haven DS0000008905.V342707.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton Devon TQ13 7UP 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
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