Inspection on 19/07/05 for St Mary`s Home

This inspection was carried out on 19th July 2005.

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

The inspector 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 Home 09/07/08

St Mary`s Home 19/10/06

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE St Mary`s Home 8 Eastbrook Place Dover Kent CT16 1RP Lead Inspector Chris Randall Announced Inspection 19 July 2005 : 09.45 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 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 Home H56-H05 SS64080 St Marys Home V239979 190705 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Marys Home Address 8 Eastbrook Place, Dover, Kent, CT16 1RP Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 02084677950 Mr A Kupendrarajah Mrs M Smith CRH 30 Category(ies) of OP registration, with number of places St Marys Home H56-H05 SS64080 St Marys Home V239979 190705 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11.01.05 Brief Description of the Service: St. Marys is a large detached property providing residential care for up to 30 service users over the age of 65. The home is located within the town of Dover and has the benefit of all local amenities within easy walking distance, and public transport nearby. The seafront is approximately 10 minutes walk away and the train station, bus terminal, Dover Ferry Port and Hoverports are all within easy reach. Accommodation is situated over four floors with a passenger lift available for easy access to all floors. There are 30 single bedrooms, all with en-suite toilet and washbasin, telephone, and call bell. Communal areas consist of four lounges on various floors, a dining room and a dedicated activities room. There are small kitchenettes on each floor where service users or their visitors can make themselves drinks. The home also has its own chapel and a hairdressing room. There is a very pleasant well-maintained garden to the rear of the property, a first floor patio area, and a small, secure car park. The new owner of the home is Mr. Kupendrarajah who also owns a home in the Maidstone area. The registered manager Mrs. Maureen Smith who has been with the home for many years. Mrs Smith is helping to ease the change from religious charity to private ownership and to maintain stability for the service users and staff. St Marys Home H56-H05 SS64080 St Marys Home V239979 190705 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was the first inspection under the new ownership of the home. The inspection process took 18 hours, (12.8 hours spent in the home over 2 days, plus preparation time). Time in the home consisted of a tour of the building and grounds; talking to the manager, most service users (12 in some depth), 14 staff, 4 visitors, 1 volunteer and the hairdresser; observing medication storage and administration; observing lunch being served; sampling lunches; observing a bingo session; both observing and joining in a keep fit/exercise session; and examination of records. The home was very clean and odour free and there was a nice atmosphere. All service users looked well cared for and happy and staffs were seen to be treating service users with respect. Visitors comments included “I am very happy, we could not have anywhere better – and I’ve got high standards”, and “they are a lovely bunch here, when our time comes we know where to come”. Service user comments included, “Its run very well indeed, everyone is looked after well and is happy and the staff are nice”, “I am very happy or I would not be here”, and I have always been most happy here, its very nice, very well run and everyone is happy here”. A staff member said, “It’s the best home I have ever worked in”. What the service does well: The home is well managed. The facilities at the home are good, and it is kept very clean and odour free Service users are treated with respect and are given choices in all aspects of their lives. Staffs are friendly and relate well to the service users, their families, and other visitors. There is a very good, varied activities programme with a dedicated activities organiser. Service users receive good food, and drinks are always available. Visitors are always made welcome at the home and are even able to make themselves drinks using the small kitchenettes that are situated around the home. One visitor said, “we can just pop in anytime and have a cup of tea, its like home from home”. St Marys Home H56-H05 SS64080 St Marys Home V239979 190705 stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Marys Home H56-H05 SS64080 St Marys Home V239979 190705 stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection St Marys Home H56-H05 SS64080 St Marys Home V239979 190705 stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4, & 5 Prospective service users can be assured that the home will meet their assessed needs, and they can stay at the home for a trial period before making any commitment to permanent occupancy. EVIDENCE: The statements of purpose and service users guides for the home have been updated to reflect the recent change in ownership and general changes within the home. All service users receive a statement of terms and conditions on admission to the home, in addition to copies of the service user guide and statement of purpose. Prior to admission prospective service users are visited, either in their own home or in hospital, to enable the manager to complete a pre admission assessment. The assessment forms used have recently been updated. In addition to this a joint assessment is obtained for any service user who is referred through care management arrangements. The information gained from these assessments is used to assess the homes ability to meet the assessed needs of the service user and to formulate the basis of the service St Marys Home H56-H05 SS64080 St Marys Home V239979 190705 stage 4.doc Version 1.40 Page 9 users care plan. The home will not accommodate service users whose needs they cannot meet. All prospective service users are invited to visit the home for a day and have a meal with the other service users to enable them to gain e a ‘feel’ for the home. The first three months of occupation (or longer if necessary) are then considered as a trial period. Emergency admissions are generally avoided. Standard 6 is not applicable to this home. St Marys Home H56-H05 SS64080 St Marys Home V239979 190705 stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10, &11 Service users are treated with respect, their dignity is maintained and their health care needs are fully supported. EVIDENCE: The home has produced a comprehensive care plan for each service user, which includes appropriate documentation including monthly reviews, details of visits to or by other professionals, and moving and handling assessments. Any possibility of pressure sores developing are referred to the District Nursing staff who give support, treatment, guidance and who arrange for any necessary equipment to be provided. The home also has a stock of its own equipment. The continence nurse visits the home at least 3 monthly. The homes activities co-ordinator, who has attended Extend training in music and movement in over 60’s, runs a keep fit class weekly. Nutritional screening is undertaken on admission and revised as necessary, the manager is considering a more formal type of documentation for this. Weights are recorded monthly. All service users are registered with the G.P. of their own choice. Chiropody, reflexology, and optician visits were all recorded. Hearing tests are organised through the service users G.P. St Marys Home H56-H05 SS64080 St Marys Home V239979 190705 stage 4.doc Version 1.40 Page 11 The home uses the Nomad system for its medication. Records of medication received, administered and leaving the home is up to date and in accordance with policy. Medication storage is appropriate, and staffs who administer medication do so sympathetically and discreetly. The home operates a system whereby controlled drugs are checked and recorded on each handover. All staffs that administer medication have received training to enable them to carry out this role efficiently. Any concerns about medication are referred to the G.P. or the pharmacist. Service users are treated with respect by the staff at the home, and their right to privacy is upheld with staff knocking on bedroom doors and waiting for an answer before entering. There is a telephone in each service users bedroom and their mail is delivered to their rooms. Medical examinations and treatment are provided in the service users own room or in private in the staff office. One service user commented, “I’ve no complaints, they look after me well, I’m very happy here and all the nurses are so nice”. The home operates clear policies and procedures for service users who are dying. As long as they can meet their needs the home will look after the service user and support them to die at home, with support from the G.P. and district nursing staff. Needs are continually reviewed and the care plan is updated as necessary throughout this time. Visitors are able to come and go as they, and the service user, wish and sometimes choose to stay with their friend or relative day and night. Staffs support visitors at this traumatic time and they are offered meals and drinks and staffs are available to pray with them if this is needed. The manager supports her staff throughout this time. Staffs from the home always attend any service users funeral. St Marys Home H56-H05 SS64080 St Marys Home V239979 190705 stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, &15 Service users continue to exercise choice, have an interesting lifestyle, retain contact with families and friends and enjoy a wholesome balanced diet. EVIDENCE: Service users at St. Mary’s have choice in all aspects of their daily lives, e.g. time of rising and retiring, where and what to eat, and what activities they wish to undertake. Service users interests are recorded in their care plan. As this home was originally run for Sister’s service users choice of religious observance is strongly upheld. The home has its own chapel and there is a weekly Eucharist held for communicants of the catholic faith and a monthly Church of England service, both of which welcome attendance by service users of any denomination The home employs a dedicated activities organiser and activities include cookery, aromatherapy, reflexology, facials, games, keep fit, and bingo. During the course of the inspection 8 service users attended the bingo session and 11 attended the keep fit. A volunteer runs a book club once a week. A hairdresser visits weekly. The home runs its own small shop and sells toiletries, stationary etc on a not for profit basis. They also have an occasional visiting clothes shop. In addition to the in house activities staff also take service users out. On the day of the inspection 6 service users chose to be St Marys Home H56-H05 SS64080 St Marys Home V239979 190705 stage 4.doc Version 1.40 Page 13 taken by staff to see The Queen who was visiting Dover. Service users comments included, “The Queen looked lovely, she was dressed in pink”, “I bought a dress here when the shop came”, “I like the exercise sessions and the book club”, and “I go to the reading club”. A visitor said, “Mother has been encouraged to join in and she is enjoying the keep fit today”. One staff member commented, “The clients are very happy and contented, they are spoiled, get choices in food, entertainment and all of their needs, its excellent”. Visitors are welcome into the home at any time to suit the service user. They are able to spend time with their loved ones either in their own rooms, in one of the various lounges, or in the garden. Visitors are always offered tea or coffee or alternatively are welcome to make their own in one of the small kitchenettes. Visitors are offered meals at the home and some occasionally bring in take away meals for themselves and the service user, which they are able to sit in the dining room to enjoy together. Visitors comments included, “my grandmother is very happy here”, “Maureen (the manager) keeps me informed about everything”, “It’s very good here, all very clean, and the staff are wonderful”. Families or powers of attorney deal with the financial affairs of most service users. However, the manager is appointee for service users who have nobody else to act for them, they all have individual bank accounts and there are 2 signatories on all transactions. One service user is currently being registered with the Court of Protection. Information regarding advocacy is printed in the homes Statement of Purpose. Service users are encouraged to bring personal possessions into the home to personalise their rooms. Service users have access to their personal records on request Service users receive a wholesome appealing and balanced diet. Lunch is three-course, there are choices at all meals, and pies and cakes are all homemade. Hot and cold drinks and snacks are available at all times, day and night. Food is nicely presented and service users can choose to eat in the dining room, in one of the lounges or in their own room. Currently the only special diets required are for diabetics but other special diets are prepared when needed. On birthdays all service users share in a birthday cake and wine and special occasions are celebrated with wine available at lunchtime. Sundays a choice of alcoholic or non-alcoholic beverage is served during the evening. The menu of the day is displayed on a white board at the entrance to the dining room. Mealtimes are unhurried and staffs give discrete assistance wherever needed. Comments from service users included, “I like the food”, “it’s always very nice” (referring to lunch), and “I am a fussy eater but I must compliment them on the food, the chef is very good”. Staff comments included “The food is lovely”, “The cook is very accommodating”, and “Food is always available for us to have a meal when we are on shift”. St Marys Home H56-H05 SS64080 St Marys Home V239979 190705 stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17, & 18 Service users can be assured that their concerns will be acted upon, that the home will protect them from any form of abuse, and their legal rights will be upheld. EVIDENCE: The home operates a simple, clear and accessible complaints procedure and copies are displayed in the home and attached to the Service Users Guide. The complaints procedure includes information on how to contact the Commission for Social Care Inspection. There has been one minor complaint since the last inspection; this was properly investigated with the outcome recorded in the complaints register. Several service users and a visitor commented, “I have no complaints”. The majority of service users who wish to vote have elected for postal votes but there are a couple that choose for their families to escort them to the polling station. The home operates an abuse and a whistle blowing policy. A copy of the latest adult protection information from the Kent County Council has been received and the manager is studying this document. The manager is an adult protection trainer and ensures that all staffs understand about the protection of vulnerable adults. All new staffs are checked against the Protection of Vulnerable Adults Register prior to employment. St Marys Home H56-H05 SS64080 St Marys Home V239979 190705 stage 4.doc Version 1.40 Page 15 The home holds ‘pocket money’ for some of the service users and this is kept safely, all transactions are properly documented, there are 2 signatures for each entry, and receipts are retained with the records. St Marys Home H56-H05 SS64080 St Marys Home V239979 190705 stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25, & 26 Service users live in a clean, safe, well maintained home with bedrooms and communal areas that meet their needs. EVIDENCE: The home is accessible, comfortable, homely and generally well maintained. Some of the accommodation is underused now the sisters have left the home and the current owner is considering various alterations to make better use of this space. The new owner has not yet had the time to address the recommendations with regard to radiator covers and flooring in the kitchen corridor made on the last inspection, although he has indicated that they will be rectified. These recommendations have been repeated on this report. A full time maintenance person is employed at the home and a programme of routine maintenance, renewal and redecoration is in place. There is also a workbook for general maintenance tasks, and special sheets for hazard notifications. The grounds are kept very tidy, safe and attractive and are accessible to service users who choose to sit or walk in the fresh air, there is a St Marys Home H56-H05 SS64080 St Marys Home V239979 190705 stage 4.doc Version 1.40 Page 17 covered walkway from the car park to the rear entrance. The environmental health officer last visited in March, the recommendations he had made on his previous visit had all been satisfactorily dealt with and there were no further recommendations. A fire risk assessment was carried out about a year ago and door guards have now been fitted throughout for additional fire safety. The home has plenty of communal space available including a dining room, several lounges, an activity room, a chapel, a hair salon, and several kitchenettes. The furnishings and lighting in communal rooms is domestic and appropriate to the needs of the service users. All service users bedrooms have en-suite toilet and washbasin facilities. In addition there are toilets available for service users on all floors where there are communal rooms. The home has five bathrooms and two shower rooms. There are several sluice rooms available. An assessment of the premises was carried out about three years ago by the manager of the time who is a qualified occupational therapist. Unfortunately this was not documented and the manager is currently seeking to address this. The home is wheelchair accessible, there is a shaft lift providing access to all upper floors, and grab rails are provided around the home. Other equipment includes bath hoists, a ‘Trixi’ and a standing hoist, slide sheets, a turntable and a car turntable, handling belts, and raised toilet seats. The board used by service users to record when they are in or out, and the buttons in the lift, have been adapted to assist a service user with visual impairment. Some of the service users rooms do not meet the sizes required by the National Minimum Standards but this is clearly documented in the homes Statement of Purpose and the lack of space is more than compensated for by the availability of communal space. All service users rooms are single and contain en-suite facilities. All bedrooms are tastefully furnished, with many service users choosing to bring in their own possessions to personalise their room. All rooms are carpeted and curtained, and have domestic style lighting and heating. Many radiators have now been covered but a recommendation has been made that the remainder should now be fitted. All rooms are fitted with a nurse call system, and all bedroom doors are fitted with locks with the service users holding their own keys unless they have been risk assessed otherwise. The home is clean and odour free. Infection control processes are in place, including liquid soap and paper towels in all toilets. The laundry is clean and tidy but the flooring needs to be replaced and a recommendation has been added to this effect. St Marys Home H56-H05 SS64080 St Marys Home V239979 190705 stage 4.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, & 30 Service users needs are met by the provision of sufficient staff, robust recruitment procedures, and suitable staff training. EVIDENCE: Staff rotas, and staff witnessed demonstrate that the home employs sufficient staff to meet the needs of the service users. In addition to the manager there are 5 carer staff on duty each morning, 7 staff early afternoon, 3 later in the afternoon, and 2 late evening. Overnight there are 2 carers on waking night duty with the manager or a senior always on call. There is also a cook, 4 domestics and a kitchen assistant on duty each day. No care staffs are under 18 and no one under 21 is left in charge of the home. Currently the home employs 20 care staff of whom 7 have obtained their NVQ 2 in care and a further 5 have been registered to start in September. Once the 5 complete their course the home will comply with the requirement of 50 of care staff trained. However as they will not complete this course before the end of the year a recommendation has been added that this training is continued. All new staffs undertake induction and foundation training. Recruitment procedures are robust. No staffs are employed until the home has received a satisfactory POVA check and 2 references. Staffs then work under supervision until a satisfactory CRB check is received. All staffs are employed in accordance with the GSCC code of conduct and receive a copy of the code. A statement of terms and conditions is prepared for all staff. CRB checks have been undertaken on all volunteers. St Marys Home H56-H05 SS64080 St Marys Home V239979 190705 stage 4.doc Version 1.40 Page 19 Staffs at the home have undertaken quite a lot of training in the past year. Recently 19 staff, including some domestics, took an Infection Control course, fire training is undertaken every 6 months. All carers have first aid, food hygiene, and moving and handling, which are updated regularly. The manager is currently planning a new moving and handling course and adult protection training. Some staffs have attended behavioural training and the activities organiser regularly updates her music and movement training. Staff comments included, “I’m going to college soon to do my NVQ”, “I have just finished my NVQ”, “I have been here for 6 years, and I only came for a few weeks, there is infinite variety, you get physically and mentally involved with people who need your help”, “I have always wanted to do care work and help people”, “Everybody here is part of a big family”, “we all get on well as a team” and “I like it, I have worked for years in care, when you walk in here there is no smell and always a good atmosphere”. Service user comments included, “The staff are smashing”, ”Everyone is so kind”, and “Maureen and the staff are all very good”. St Marys Home H56-H05 SS64080 St Marys Home V239979 190705 stage 4.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, 36, 37, & 38 Good management and effective administration procedures ensure effective support to service users EVIDENCE: The registered manager has been in post for the past three years, she has a background in orthopaedic nursing. Although Maureen has not yet completed her NVQ4/RMA this is due to the lack of support from her original training provider. She is now registered with the college and is already half way through the training. She also attends other training courses recently having attended both a moving and handling trainers course and an infection control course There are clear lines of accountability within the home and between the manager and the provider. The management approach and ethos of the home is open, positive, and inclusive, and the manager communicates a clear sense of direction and leadership, Staff members commented, “Its strict here but that is good”, “the manager is very supportive”, and “I’m given lots of support St Marys Home H56-H05 SS64080 St Marys Home V239979 190705 stage 4.doc Version 1.40 Page 21 – if I want anything its always there”. A service user commented, “Maureen is very good at her job, and she always chooses good staff”. Quality assurance questionnaires are sent out annually to service users, relatives and friends, and visiting professionals. A summary of responses is published in the service user guide. This years questionnaires are being sent out in September to give all concerned the chance to assess the situation under new ownership. Comments on the pre-inspection questionnaires circulated by the Commission were all positive. The new owner is arranging for the Regulation 26 visits to be carried out by a Quality Auditor from the Kent Care Homes Association. Insurance cover is up to date and at an appropriate level, and the home is financially viable. As previously mentioned the families or powers of attorney deal with the financial affairs of most service users. Any monies handled by the home are securely stored and properly accounted for with 2 signatories for each transaction and with each service user having their own individual bank accounts. The home holds valuables for some service users and these are kept securely with receipts issued. All records in the home are effective, up to date, accurate, and stored securely. All staffs receive annual appraisals. Staff supervision is also in place but at present this is not formal and not effectively documented. A recommendation is made to rectify this. The manager ensures staffs are trained and proficient in statutory requirements. COSHH substances are correctly stored and documented. Certificates witnessed regarding health and safety and servicing of equipment were all up to date. Risk assessments are carried out for all safe working practices. Accidents and injuries are properly documented and the manager checks on trends and refers to relevant professionals when necessary. Comments received from staff included, “Its been a bit stressful with the changes but Maureen has supported us, I feel very reassured and so do the residents, we had a meeting with the new owner and he seems very approachable and genuine”, “I have been a bit apprehensive about the take over but he seems really nice and everything has stayed the same. He has a good sense of humour”, and “The new owner seems alright – he has told us our jobs are safe”. St Marys Home H56-H05 SS64080 St Marys Home V239979 190705 stage 4.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 3 3 3 2 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 2 3 3 St Marys Home H56-H05 SS64080 St Marys Home V239979 190705 stage 4.doc Version 1.40 Page 23 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. 1. 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. 2. 3. 4. 5. Refer to Standard 19.1 25.5 26.4 28.1 36.2 Good Practice Recommendations The kitchen flooring, particularly in the walkway alongside the kitchen, should be replaced. Pipework and radiators should be guarded or have guaranteed low temperature surfaces. The laundry flooring should be replaced to ensure the finish is impermeable. Care staff to continue with NVQ 2 training to ensure that a minimum of 50 attain this qualification Staff supervisions should be formal and documented St Marys Home H56-H05 SS64080 St Marys Home V239979 190705 stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 11th Floor International House Dover Place Ashoford Kent TN23 1HU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Marys Home H56-H05 SS64080 St Marys Home V239979 190705 stage 4.doc Version 1.40 Page 25 - 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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