Inspection on 19/10/06 for St Mary`s Home

This inspection was carried out on 19th October 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Mary`s Home 09/07/08

St Mary`s Home 19/07/05

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 St Mary`s 8 Eastbrook Place Dover Kent CT16 1RP Lead Inspector Mrs Penny McMullan Unannounced Inspection 09:30 19 and 20 October 2006 th th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Mary`s Home DS0000064080.V311366.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 Home DS0000064080.V311366.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary`s Home Address St Mary`s 8 Eastbrook Place Dover Kent CT16 1RP 01304 204232 01304 207138 maureensmith1204@aol.com 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) Mr A Kupendrarajah Mrs M Smith Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places St Mary`s Home DS0000064080.V311366.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 2005 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 and Dover Ferry Port 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 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. The current fees for the service at the time of the visit are £303 to £364 per week. Information on the homes services and the CSCI reports for prospective service users/relatives will be referred to in the Service User Guide. The inspection report is also in display in the receiption area. The email address is: maureensmith1204@aol.com St Mary`s Home DS0000064080.V311366.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced site visit took place on Thursday 19th October 2006 and Friday 20th October, the Registered Manager Mrs Maureen Smith was in attendance. The inspection includes feedback from service users, relatives, Care Management, and discussion with staff and management. Five service users returned the postal survey; two relatives comments were received and comments from the Care Management Team are also included in this report. All comments received from the services users and relatives are complimentary to the Management, staff and care services being provided. Care Management say ‘St Mary’s is an excellent home, extremely well run, they communicate well and are able to meet complex individual care needs when required’ The Registered Provider has plans to extend the service in an area on the ground floor, which has not previously been used in the home and will be applying to the Commission to amend the registration to include a separate unit to provide specialist services. The home has a stimulating activity programme in place, which is varied and interesting. Service users enjoy the programme and play an active part in the daily living in the home. The home has been exceeded this standard and has been scored as commendable. What the service does well: The home has a relaxed friendly welcome and is well managed. The facilities at the home are good, and standards of cleanliness are high ensuring there are no offensive odours. Service users have choice in the daily living in the home and in all aspects of their care. The relationship between the staff and service users is positive, friendly and respectful. There is a dedicated activity coordinator and the home provides a varied stimulating programme of activities. Service users say the food is good with choices and variety. Service User Comment: ‘I like my room, the food is good and I enjoy the activities’. St Mary`s Home DS0000064080.V311366.R01.S.doc Version 5.2 Page 6 ‘We all love it here’, it is marvellous’ there is nothing to complain about it’s lovely’. ‘This is a very nice, comfortable home; the staff look after me well. My room is not big but I am happy with it. Staff are really lovely, could not wish for a better service’. ‘I cannot fault the home, I have no complaints or grumbles, if I did I would speak to Maureen, the Manager’. ‘My bedroom is small but I like it, it looks out to the park and I can get up or go to my room when I wish’ ‘I love it here. There are lots of different things you can do here’. ‘There is a good atmosphere in the home. The home does everything well. I have no complaints. I cannot fault the home, no member of staff to complain about. Maureen the Manager does a wonderful job’ ‘I have been here several years and the health and hygiene is a very high standard, medical care is a great tribute to those who look after us’ One relative comment says ‘my mother frequently says how she likes her room, and the bed is comfortable. She enjoys the food and says they have a laugh. She says the staff are very nice and they have laughs together. She’s happy.’ Another relative says ‘One relative comment says ‘I was impressed with the information given on my initial visit and the following phone calls.’ What has improved since the last inspection? What they could do better: One service users comment: ‘the home could not do anything better’ Detailed care plans are in place together with risk assessments; however further detail is required to ensure that staff have clear guidelines in place to ensure that service users are moved safely. The home needs to ensure that hand written entries on the medication administration sheets are countersigned to minimise the risk of error and St Mary`s Home DS0000064080.V311366.R01.S.doc Version 5.2 Page 7 provide dedicated cold storage. Further detail is required when medication risk assessments are in place. A requirement has been made in this report. Staff have not received adult protection training. The home must ensure that two satisfactory references are in place prior to commencement of employment of staff. A requirement has been made in this report. The home is going to address the recommendation with regard to the repair of the laundry floor when the refurbishment takes place on the ground floor. Although staff feels supported by the Manager, formal supervision is not up to date. A recommendation has been made in this report. 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 Mary`s Home DS0000064080.V311366.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 Home DS0000064080.V311366.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to carry out a detailed and through assessments of needs of service users prior to admission to the home to ensure that all care needs will be met. Standard 6 does not apply to this home. EVIDENCE: One service user confirmed that the Manager had been to see her with regard to the admission to the home. The Manager visits service users prior to admission to complete a pre admission assessment. This information is included in the care plan and joint assessments from the placing authority are also on file. St Mary`s Home DS0000064080.V311366.R01.S.doc Version 5.2 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 the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a consistent care planning system in place to provide staff with the information they need to meet Service Users health and social care needs. There systems for medication administration are good however there are minor shortfalls in storage and recording. The home promotes service users rights and choices. EVIDENCE: Service user plans are detailed and include all aspects of health and social care, however there are minor shortfalls in the risk assessments. The guidelines for staff require further detail to ensure that staff have clear guidelines and provide a safe practice of work. A recommendation has been made in this report. Care plans are reviewed monthly and service users are aware of the plans but did not express a wish to view them. Daily records are in place and these are read to all carers during handover to ensure staff are kept up to date with the care being provided. St Mary`s Home DS0000064080.V311366.R01.S.doc Version 5.2 Page 11 All health care needs are monitored in the care plan and if necessary referred to the District Nurse, Continence nurse or specific health care professional. 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 and weights are monitored each month. Service users confirmed that the chiropodist and optician visits the home and when required they attend out patient, appointments with a relative. The home uses the Nomad system for the administration of medication and two senior staff are responsible for the receipt and recording of medication. The home has been experiencing some difficult with regard to the pharmacy recording the medication on the medical administration sheet (MAR Sheet) whish has resulted in the home hand writing entries on to the sheets. Two staff is checking the information however all written entries in the mar sheet need to be countersigned to minimise the risk of error. There is currently no specific medication refrigerator and the home is now going to purchase one for the sole use of medication. The home has written instructions with regard to individual preferences when receiving medication however this information needs to include further details with regard to risk assessment. A requirement has been made in this report. Medication storage and the controlled drug system are satisfactory. All staff administering medication has received training and the Registered Manager has recently trained to be an assessor. Any refusals of medication are reported to the Manager to take the appropriate action with the GP. Service users confirmed that staff treat them with respect and dignity. They say the staff always knock on their door and pause before entering. One service user says ‘the staff are very sensitive when it comes to providing personal care’. There is a telephone in each service users bedroom and mail is delivered to each service user either in their room or the lounge. St Mary`s Home DS0000064080.V311366.R01.S.doc Version 5.2 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 the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an excellent activities programme, which provides stimulating activities to meet the needs and choices of the service users. Visitors are able to visit the home at any time and see their relative in private. The home supports residents with financial or advocacy information to promote resident’s autonomy and choice. Dietary needs of Service Users are well catered for with a balanced and varied selection of food available that meets Service Users tastes and choices. EVIDENCE: The home employs a dedicated activities organiser who is qualified to provide armchair aerobics. She also organises aromatherapy, facials, hand and foot massage, games, story time, cooking, keep fit, knitting, embroidery, bingo and poetry. One service user is completing a degree course at the local college. One service user says ‘there are lots of different things you can do, the home organises schools to visit and sing, and other people entertain in the lounge, there is a music man and violinist’. Another service users stated that the book St Mary`s Home DS0000064080.V311366.R01.S.doc Version 5.2 Page 13 club discusses the authors and the contents of the book but she is unable to attend at the moment as the session clashes with another activity. Large print books are available. The home also runs its own small shop and sells toiletries, stationary etc on a not for profit basis. On occasions a visiting clothes shop also comes to the home. Service users are encouraged to go on outings and staff will also take service users out. All service users spoken to say that the home provides varied activities and you have choice if you wish to join in. The atmosphere in the home around activities was positive and inclusive with service users looking forward to the cooking session in the afternoon. The service users made three different sorts of biscuits, which were served with tea in the afternoon. This standard has been scored as 4, which is standard exceeded (commendable). All service users spoken to confirmed visitors are welcome. They are able to see them in their own bedroom, lounge or quiet room. There are small kitchen facilities in the home where visitors can make their own tea. Staff are made aware of any restrictions on visitors. Staff are aware of the procedure if there are restrictions on visiting. One service user is able to invite her colleagues on the course to have tea and watch videos in the quiet room. Relatives or powers of attorney deal with the financial affairs of most service users, although some are supported by the home to ensure they are able to handle their own financial affairs. Information regarding advocacy is included the Statement of Purpose. Service users gave examples of their choice with regard to food, activities and daily life. One service user says she is able to make her bed and tries to do things for herself. Service users spoken to say they choose when to go to bed or get up, where and what to eat, and what activities they wish to undertake. There is a four weekly menu in place and service users say the food is really good, it looked appetising and each day there is a three-course meal. Fruit juice or water is served with the meal and on Sunday’s service users are offered wine at lunch time and in the evening alcoholic or non-alcoholic beverages are also served. The majority of the food is home made especially the cakes and soups and a variety of cooked teas are provided. The chef was observed talking to each individual service user with regard to choices and the atmosphere in the dining room was relaxed and unhurried. There are no special dietary requirements at present. The menu of the day is displayed on a white board at the entrance to the dining room. St Mary`s Home DS0000064080.V311366.R01.S.doc Version 5.2 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 the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for protecting Service Users are satisfactory however there are minor shortfalls in adult protection training for staff. The home has a satisfactory complaints system with some evidence that Service Users feel that their views are listened to and acted on. EVIDENCE: All service users spoken to did not have any complaints but all said they would complain to Maureen the Manager if they had any concerns. Arrangements are in place for the recording of complaints and all complaints have been responded to appropriately. Staff demonstrated their awareness to adult protection issues. The home has a policy, which includes whistle blowing, and the Manager is a trainer for trainers in Adult Protection. Staff are able to demonstrate their awareness of adult protection and have covered some of this whilst completing NVQ however the home has not provided training. A recommendation has been made in this report. St Mary`s Home DS0000064080.V311366.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 19,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained and decorated ensuring that residents are living in pleasant homely environment. Laundry facilities are satisfactory and policies and procedures are in place to control the risk of infection. EVIDENCE: The home well maintained, comfortable and homely. The kitchen floor has been repaired. The home now has a new maintenance person who is employed to work three days per week. 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 covered walkway from the car park to the rear entrance. St Mary`s Home DS0000064080.V311366.R01.S.doc Version 5.2 Page 16 The environmental health officer visited the home last year and a fire risk assessment is also in place. The Manager is in the process of reviewing this document in line with new guidance for care homes. There are only four radiators left to cover in the home and the maintenance man will address this problem in the near future. 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. One service user says ‘my room is small but I like it’. All service users rooms are single with en-suite facilities. Rooms are personalised to service users individual choices. 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, tidy and there are no offensive odours. 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. The Manager says that this will be replaced when the refurbishment on the ground floor takes place. A recommendation made in the last inspection report will be therefore be brought forward in this report. St Mary`s Home DS0000064080.V311366.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient trained and qualified staff are provided to ensure Service Users needs are met. Recruitment polices have not been consistently followed resulting in Service Users receiving care from staff that have not been fully vetted. EVIDENCE: There is a minimum of five staff on each day shift and two waking night staff, with a manager or senior on call. The home employs an Activities Co-ordinator on duty for part of the week, chef, domestic staff and kitchen assistance. The Registered Manager and the administrator were also on duty. Service users say that there is always enough staff on duty and they respond well to the call bell even during the night. The home has 55 of staff who are NVQ 2 or above. All new staffs undertake induction and foundation training. One new member of staff confirmed that she is completing her induction training, which included two days studying polices, and procedures, shadowing and working routines of the home. Recruitments records show that one newly recruited staff member records contained a Criminal Records Bureau (CRB) and Protection of Venerable Adult St Mary`s Home DS0000064080.V311366.R01.S.doc Version 5.2 Page 18 (POVA) check was in place. However there was no evidence of two satisfactory references being received. A requirement has been made in this report. Staff employed in the home prior to receipt of these documents are supervision until a satisfactory CRB check is received. CRB checks have been undertaken on all volunteers. Each individual staff member has a training profile however there is no matrix to summarise all training being provided. Mandatory training is being provided and the Manager is a Moving and Handling Training and will be updating all staff. The new staff require training which is in the process of being arranged. First aid training is also being updated. Apart from the 3 new members of staff all carers have first aid, food hygiene, and moving and handling, which are updated regularly. The Activity Organiser has recently updated her Extend training in music and movement in the over 65’s. St Mary`s Home DS0000064080.V311366.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run effectively managed home. The arrangements for service user consultation are good. The home has implemented an effective financial system to support residents with their finances. Staff feel supported and valued although there are shortfalls in the provision of formal recorded supervision. The home provides a safe environment for service users and staff. EVIDENCE: St Mary`s Home DS0000064080.V311366.R01.S.doc Version 5.2 Page 20 The registered manager has been in post for the past four years, she has a background in orthopaedic nursing and is very experienced in caring for people. She has completed one NVQ 4 portfolio and is in the process of completing the award. The management approach and ethos of the home is open, positive, and inclusive. All of the service users spoken to are very complimentary about the Manager’ skills and it is evident from the positive relationships, which have been formed between the staff and Service Users. Staff say they feel supported and valued by the Manager and they all work well as a team. Quality Assurance is carried out on a yearly basis. There is a quality assurance questionnaire in process, which covers relatives and residents and visiting professionals. The results will be summarised and included in the service user guide. The owner of the home ensures that the home is visited monthly to ensure that the home is providing good quality care. Service users involvement in the home is apparent by the positive comments made in this report. The home looks after some service users financial affairs and in one instance the system of receiving monies needs to be reviewed. The Registered manager will be consulting the Registered Provider to discuss this issue. Families or powers of attorney are involved with some service users. Any monies handled by the home are securely stored and properly accounted for with two 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 also kept securely with receipts issued. The majority of records in the home are effective, up to date, accurate, and stored securely. Annual appraisals were carried out last year and are in the process of being organised for this year. The staff supervision programme is in place but this is not up to date. The Registered Manager works well with the staff and is fully aware of service users needs and provides supervision and support during the working day however this is not always formalised as supervision. The Manager carries out all supervisions and would benefit from a senior member of staff supporting her in this role. A recommendation is made in this report. Staff say they feel supported by the Manager to do their job well. The home is providing mandatory training. All necessary equipment has been serviced and safety maintenance checks have been carried out. All portable appliances have also been tested. The fire register was up to date and in good order. Risk assessments are in place including fire risk assessment and environment risk assessments. Accident recording is satisfactory with evidence that incidents/accidents are monitored and actioned accordingly. St Mary`s Home DS0000064080.V311366.R01.S.doc Version 5.2 Page 21 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 3 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x 3 2 x 3 St Mary`s Home DS0000064080.V311366.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 OP9 Regulation 13 Requirement The home needs to ensure that hand written entries on the medication administration sheets are countersigned to minimise the risk of error To provide dedicated cold storage. Risk Assessments require further detail To ensure that two satisfactory references are in place prior to employment Timescale for action 22/12/06 2 OP29 16 22/12/06 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 OP7 OP18 Good Practice Recommendations Risk assessments in service user plans require further detail to ensure that staff have clear guidelines and provide a safe practice of work. To provide staff with Adult Protection Training DS0000064080.V311366.R01.S.doc Version 5.2 Page 23 St Mary`s Home 3 4 5 OP25 OP26 OP36 Pipework and radiators should be guarded or have guaranteed low temperature surfaces. The laundry flooring should be replaced to ensure the finish is impermeable. This has been brought forward form the last inspection 19/7/06 Staff supervisions should be formal and documented, this has been brought forward from the previous inspection 19/7/06 St Mary`s Home DS0000064080.V311366.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford 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 Mary`s Home DS0000064080.V311366.R01.S.doc Version 5.2 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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