Inspection on 31/08/06 for St Mary`s Home

This inspection was carried out on 31st August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Mary`s Home 11/01/06

St Mary`s Home 22/07/05

St Mary`s Home 28/02/05

St Mary`s Home 17/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 St Mary`s Home Roehampton High Street London SW15 4HJ Lead Inspector Davina McLaverty Unannounced Inspection 31st August 2006 & 4 September 2006 10:00 th St Mary`s Home DS0000010230.V309096.R01.S.doc Version 5.2 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 DS0000010230.V309096.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 Adults 18-65. 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 DS0000010230.V309096.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary`s Home Address Roehampton High Street London SW15 4HJ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8788 6186 020 8788 1054 ljdowling@aol.com The Frances Taylor Foundation Mr Finton O’Reilly (subject to CSCI approval) Care Home 42 Category(ies) of Dementia - over 65 years of age (13), Learning registration, with number disability (42) of places St Mary`s Home DS0000010230.V309096.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11 January 2006 Brief Description of the Service: St Marys is a care home for 42 adults with a learning disability. The home is located on the High Street in Roehampton, close to shops, pubs, the post office and other amenities. It is owned by The Poor Servants of the Mother of God, a voluntary organisation and is managed by The Frances Taylor Foundation. A copy of the last inspection report is displayed in the home. The current weekly fees that are charged at St Mary’s start from £469.71 to 922.50 St Mary`s Home DS0000010230.V309096.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days and was conducted by one regulation inspector. The inspector met fifteen residents, the deputy manager and six support staff. A number of records were examined, which included residents care plans, medication records, staff and residents meeting minutes, health and safety and staff records. A tour of the premises took place. Verbal communication with several of the residents was difficult due to the level of their learning disability. However, the inspector spoke at some length with four residents who were all very positive about the home and support received. One resident described the home as, “very good, as the staff helped you to do the things you cannot do yourself”. Another said that the staff team are,” kind and considerate, take good care of everyone and that there is a nice relaxed atmosphere throughout the home”. Another spoke enthusiastically of her trips out and her forthcoming holiday. Residents were observed to be relaxed, were appropriately dressed with attention having being paid to colour co-ordination. Prior to the inspection taking place, questionnaires were sent out by the Commission to the home for residents to complete, and sent directly to a number of professionals and relatives of residents. Eleven questionnaires were received from relatives, six from health care professionals and eleven from residents, seven of whom had been supported by staff in the home to complete the form. The majority of comments received were positive regarding the home and the care received. Some of these comments are reflected throughout the report. What the service does well: Staff support residents to maintain their independence and individual interests. The care of the resident is the primary focus of the home and staff work hard to ensure this is achieved. Staff spoken with demonstrated a good understanding of resident’s needs and the inspector observed positive and caring interactions between staff and residents. The inspector found high levels of satisfaction in the home in relation to the care provided, the food and the environment. Comments from residents about the home included, “ this is a good home”, “the staff are marvellous” and I’m happy here, they are all kind to me”. St Mary`s Home DS0000010230.V309096.R01.S.doc Version 5.2 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 Mary`s Home DS0000010230.V309096.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Mary`s Home DS0000010230.V309096.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 & 4 Quality in this area is adequate. This judgement had been made using available evidence including a visit to this service. Prospective resident representatives will have information they need to make an informed choice about the home and its suitability for a prospective resident. An organisational assessment procedure is in place. However, full details of assessments were not seen on all the residents files examined. EVIDENCE: A Statement of Purpose is in place, which contains information about the organisation and describes the care offered at the home. The document along with the Service users guide, enables the resident, or their representative to make an informed choice regarding the suitability of the home. However, both documents require updating. The deputy manager said that the organisation is currently addressing this. Several of the residents have lived in the home for many years; four files were examined of new residents. Files seen had a lot of information on them, but comprehensive assessments were not seen to be in place. Two application forms were not fully completed. No file examined contained a completed assessment and admission form as stated in the organisation’s operational policy. Staff must ensure that they comply with the policy and obtain sufficient assessment information prior to admitting the resident. St Mary`s Home DS0000010230.V309096.R01.S.doc Version 5.2 Page 9 The Francis Taylor Foundation admission procedure encourages several visits to the home for the prospective resident and their representatives. The deputy stated that this definitely occurred, as it enabled residents to get a feel of the service and find out whether or not it will be able to meet their needs. St Mary`s Home DS0000010230.V309096.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this area is good. This judgement had been made using available evidence including a visit to this service. Care Plans are good and include clear goals to provide staff with the information they need to satisfactorily meet residents needs. Residents continue to be encouraged to make decisions about their lives with support from the staff and where goals have been identified they are specific to the individual. Risk taking is acknowledged by staff as part of developing an independent life and individual assessments are carried out to support this. EVIDENCE: Care documentation for four residents were examined. The files were seen to contain up to date and comprehensive information about the residents and their needs. They all contained goals, that had as far as possible, been discussed with the resident by their key workers. Two residents spoken with discussed their involvement in their care plans, which also included a health action plan. Reviews were seen to have taken place and two residents spoke of their reviews. Person Centred Plans were in the process of being developed St Mary`s Home DS0000010230.V309096.R01.S.doc Version 5.2 Page 11 and those seen varied in content and layout, which reflected individual needs. Plans included likes and dislikes, goals and aspirations. Staff reported that where residents are unable to communicate, they tried to involve relatives. One purchaser in their questionnaire stated that the organisation needed to be more pro-active in this area. Another stated that reviews tend to be on dates that the home arrange and have gone ahead with little consultation on occasions. In response to this the deputy stated that in order to ensure that all residents have reviews dates are set and sent to purchasers. Dates can be negotiated or additional reviews held if need be. Risk assessments continue to address areas of risk such as moving and handling, self - administration and safe use of hot water. Regular reviews take place. The home operates a key worker system, which endeavours to promote continuity of care. The residents spoken with were aware of who their key worker were and several residents are clearly involved in contributing to how they want to be supported. Staff spoken to, had a sound knowledge of their key residents and philosophy of the home. Staff were seen to be supportive and sensitive to residents throughout the inspection visit. Care staff work to a high standard to ensure residents receive the care they need. Three residents spoken to in their lounge reported that they were very satisfied with the overall service provided. They said that they were well looked after and really enjoyed living there. Four other residents spoken with individually, reiterated what the group of residents had said. Relatives, in their questionnaires on the whole, reported favourably with comments as follows, “The social activities take into account her love of music and include that aspect into her life wherever possible”. “I am made welcomed whenever we visited”, “My daughter spends about 9 nights a year at the home at the moment. She finds the staff very helpful and friendly and is quite happy with the way the care home is run. I would like to say thank you to all the staff at St Mary’s”, and “All staff seem to take an interest in my sister’s care. They go to considerable lengths to accommodate her sometimes demanding needs. I am very pleased with the care given by St Mary’s”. However, two relative raised concerns regarding lack of music in the home, and would like to see their relative being taken out more. Another felt that communication could be improved and cited the disappearance of the home’s newsletter. These comments were raised with the deputy manager, who stated that the newsletter was in the process of being resurrected. The inspector saw evidence of this. In respect to trips out, this was found not to be the case as the home was found to provide a wide range of activities both in and out of the home. One professional in their questionnaire stated that, “St Mary’s has highly specialist skills in managing people with Downs Syndrome and Dementia and works extremely well in partnership with the Community Learning Disability service”. St Mary`s Home DS0000010230.V309096.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 & 17 Quality in this area is good. This judgement had been made using available evidence including a visit to this service. This home continues to maintain good links with the community, which enriches residents lives. The home provides a very good environment for them to develop their social skills, as far as they are able. The service promotes independence and individual choice for the residents accommodated. Individual dietary needs are well catered for. EVIDENCE: Dependency levels varied within the home, resulting in residents care packages varying significantly. St Mary’s has its own day centre, which some of the residents attend. There is also an art room and multi-sensorial room. A number of residents also attend mass weekly in the church. There is a range of television, video and music equipment for residents use in the communal lounge areas. Residents spoken with stated that they also had their own televisions and radios in their rooms, which the inspector saw. St Mary`s Home DS0000010230.V309096.R01.S.doc Version 5.2 Page 13 The home has its own transport enabling unplanned trips to take place, subject to drivers. Regular trips occur and residents spoke of recent trips to the Tate art gallery, London Dungeons, Madame Tussauds, Brighton, and Weymouth as well as more local trips to parks and cafes. Several residents spoke of their forthcoming holiday to Ireland. Another spoke of their trip to Weymouth, which they really enjoyed. Residents and staff spoke of the home encouraging relatives and friends to visit. Birthday’s parties take place and occasional social events to which family and friends are invited. Ten out of the eleven questionnaires received stated that they are always made to feel welcomed. However, one relative stated that they would like there to be better communication between the home and relatives. The person stated that the newsletter no longer existed. In discussion with the deputy she stated that due to staff changes within the home this had been lost but the newsletter was due to be sent out later on this year. Each floor has a diary, which records day’s activities. However, on examination of the two diaries they tended to focus on care issues e.g. personal care, dietary and bowel movement. Diaries should reflect how individuals have spent their day including activities in and out of the home. Residents are encouraged to get involve in the preparation of meals, and domestic chores, as they are able. The inspector observed various residents contributing to the preparation of lunch e.g. setting the table, getting food from the cupboards in preparation for the meals. Individual meals were prepared on the various floors reflecting individual choice The menu showed that residents are offered a varied range of foods. The inspector saw different meals being prepared on the units according to resident’s choice. Staff reported that most meals are prepared from fresh and that healthy eating is encouraged. Food can be blended /pureed for residents as required. Residents spoken with stated how much they enjoyed the food. Five residents reported that the food is good and that there was always a choice. Occasional take-aways are also purchased. Staff were observed to be very patient with the residents, particularly when supporting them eat. One new staff member spoke of how she got to know the residents who cannot communicate verbally through their facial and body language and spoke positively about the residents. St Mary`s Home DS0000010230.V309096.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this area is good. This judgement had been made using available evidence including a visit to this service. Residents receive appropriate levels of support to ensure their physical health needs are met. Systems are in maintained to ensure the safe administration of medication to residents. EVIDENCE: Evidence was seen in the care plans examined of input from health care professionals including: GPs, hospital consultants, dieticians and social workers. Personal aids and equipment are available and well maintained to support both residents and staff in daily living. Support staff stated that they provide various degrees of support to residents in respect of personal care depending on individual abilities. Residents are encouraged to do as much for themselves as possible. One resident said, “the staff help me to do the things I cannot do by myself”. No concerns were raised from the health care questionnaire received. It was stated, “Individual Care Needs met very well”. St Mary`s Home DS0000010230.V309096.R01.S.doc Version 5.2 Page 15 A medication policy is in place at the home. Medication currently in use is stored on resident’s floors in individual sealed containers. The inspector was informed that the organisation is currently looking at getting new medication cabinets in the four units and is in the process of consulting with the pharmacist. Surplus medication is stored in cabinets in the medicine/consultation room on the ground floor. Medication records were checked in two of the units and contained no errors. Two staff members sign when medication is administered. New photographs of residents are in the process of being added to the medication records sheets. Sample signatures of staff were in evidence again this will be updated when new staff have completed their training. All staff receive training in the administration of medication. Currently, three residents self medicate and keep their own medication in a locked cupboard in their room. Current risk assessments are in place. The homes General practitioner visits weekly. St Mary`s Home DS0000010230.V309096.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this area is good. This judgement had been made using available evidence including a visit to this service. An appropriate written procedure is available. Organisational policies and procedures are in place to protect residents from abuse. EVIDENCE: The manager stated that there has been no formal complaints received in the home since the last inspection and the Commission has not received any complaints either. No issues were raised regarding the home, staff and care received at the home by residents. One resident said that they feel very safe and well supported by the organisation. A copy of the complaint procedure was seen in two units. Policies and procedures are in place for the protection of vulnerable adults. Staff spoken to were aware of the organisation’s whistle blowing policy and said that they did not have any concerns or issues. St Mary`s Home DS0000010230.V309096.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 Quality in this area is good. This judgement had been made using available evidence including a visit to this service. The home was seen to be well maintained. Bedrooms and communal areas were furnished to a high standard. The home was found to be clean on the day of the inspection. EVIDENCE: The home provides comfortable and well-maintained accommodation to the residents who live there. CCTV is available with an entry phone system. Staff must continue to challenge strangers in the building who have been let in. The inspector was not challenged or taken to the person in charge, despite it being a first visit to the home. This was raised with the deputy manager who said that she would raise it again with all staff and residents. The second day of the inspection the inspector was taken to the shift leader. Bedrooms were seen to be personalised. Various rooms seen had specialised equipment e.g. raised beds, ripple mattresses. As stated earlier, the home consists of four units. Each unit has its own character, which reflect the needs and likes of the residents. Separate lounges St Mary`s Home DS0000010230.V309096.R01.S.doc Version 5.2 Page 18 and kitchens are available on each floor. Residents on the top floor are more independent and spoke of their involvement in choosing what went into the lounge e.g. pictures, ornaments etc. The bathrooms and toilets were also fitted with appropriate aids and adaptations to meet the needs of the people who use the service. Bathrooms are sufficient in number. The home is currently in the process of converting the treatment room and bathroom on the ground floor into one large bathroom, which will better accommodate wheelchair users and will better accommodate the parker bath and will have a tracking hoist. A large laundry with appropriate washing and drying appliances is available on the ground floor. Resident’s belongings are washed communally, as everything is labelled. Staff endeavour to ensure that clothes do not go astray but on occasions this has occurred. A large art room and multi-sensorial room is also available for residents. The home also has its own well-equipped day centre. A large well maintained garden is available as well as a patio area. The deputy manager stated that consideration is currently being given to redesigning the patio area due to the dependency levels of residents and number of wheelchair users. Garden furniture was available. The home was found to be clean and tidy on the day of the inspection. St Mary`s Home DS0000010230.V309096.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 Quality in this area is adequate. This judgement had been made using available evidence including a visit to this service. The training provided helps to ensure that a well-informed staff group supports residents. Recruitment checks failed to evidence that all the required checks had been carried out. Staff meetings and staff supervision take place regularly. EVIDENCE: The deputy manager reported that the home currently had one support staff vacancy. The home operates with three staff on each floor with the exception of the third floor, which has one or two, as the residents there are more independent. At night there are two waking night and one staff asleep but on call. Additional staff may be rostered depending on what activities are taking place and what some individuals may want to do. The deputy manager and all three staff spoken with stated that staffing levels were adequate. Staff are aware of the importance of team working and reported that they worked well together. Staff described the deputy and manager as available and “hands on”. The inspector spoke to three support staff who varied in length of service within the home. All were very positive about the support and care given to residents. Comments included, “ We look after our residents very well”, “ The care and support here is very good”, and “Team work is good”. These St Mary`s Home DS0000010230.V309096.R01.S.doc Version 5.2 Page 20 comments were reflected in comments received during the inspection from the residents and in all the questionnaires received. Five staff files were examined and none contained all the required documentation for the recruiting of staff e.g. two lacked two references with only one seen. Criminal Bureau checks outcomes were not seen on three of the files examined. Two files contained only one reference; three had no current photograph on them. The organisation must ensure that all required checks detailed in Schedule 2 of the Care Homes Regulations are available on staff files. The manager however, was in the process of adding staff training records and supervision records to these files. The manager was also in the process of updating all staff core training and records were available to evidence this. Staff spoken to were all positive about training. The majority of staff had completed their NVQ in Care Qualification and all staff spoke positively of the training offered by the organisation. The senior staff reported that new systems had been introduced in June regarding supervision, which takes place monthly, of which the inspector saw evidence. Staff meetings take place monthly, as do individual floor meetings. St Mary`s Home DS0000010230.V309096.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this area is good. This judgement had been made using available evidence including a visit to this service. A quality assurance system is in place. Systems are in place to ensure the health and safety of residents and staff. EVIDENCE: Since the last inspection an application is still outstanding from the manager for approval by the Commission For Social Care Inspection. The manager was on leave at the time of the inspection, which was carried out with the deputy manager who has been in post since June 06 although had worked for the organisation for 4 years. Regulation 26 monthly visits take place and copies of these visits are forwarded to the Commission as well as a copy being retained in the home. St Mary`s Home DS0000010230.V309096.R01.S.doc Version 5.2 Page 22 A quality assurance system is in place, which seeks the views of residents, relatives and other stakeholders. Questionnaires are sent out annually on return, collated and necessary changes made. Residents meetings should take place more frequently within the home. Records showed that staff make regular checks on the building and equipment in the home and that the health, safety and welfare of residents are promoted and protected. Sample records seen included the monthly fire drills, fire service visits, portable appliance test, fridge and freezer temperature and the emergency lighting checks. The home’s gas certificate could not be located neither could the weekly fire test records, which staff said took place weekly. St Mary`s Home DS0000010230.V309096.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 2 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 2 X St Mary`s Home DS0000010230.V309096.R01.S.doc Version 5.2 Page 24 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 YA2 Regulation 14(1) Requirement The Registered must ensure that new residents are admitted only after a current assessment has taken place and a copy received and that the organisations admissions policy is adhered to in respect of completion of documents. The Registered Person must ensure that documents detailed in Schedule 2 of the care Homes Regulations are obtained and available in the home prior to staff starting. The Registered Persons must ensure that an application is submitted to the CSCI for registration of a manager for the home. (Timeframe of 01/03/06 not met) The Registered Person must keep a copy of the homes annual gas inspection in the health and safety file of the home. The Registered Person must ensure that a written record is maintained of the weekly fire alarm tests. DS0000010230.V309096.R01.S.doc Timescale for action 01/10/06 2 YA34 Schedule 2 7,9,19 31/08/06 3. YA37 8 (1) 30/09/06 4 YA42 17(2) 30/09/06 4 YA42 17(2) 31/08/06 St Mary`s Home Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA14 Good Practice Recommendations The Registered Persons should ensure that there is a clear written record of activities residents participate in both in and out of the home. St Mary`s Home DS0000010230.V309096.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 DS0000010230.V309096.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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