Inspection on 09/07/08 for St Mary`s Home

This inspection was carried out on 9th July 2008.

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 19/10/06

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE St Mary`s Home 8 Eastbrook Place Dover Kent CT16 1RP Lead Inspector Mrs Penny McMullan Unannounced Inspection 9th July 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Mary`s Home DS0000064080.V367031.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.V367031.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary`s Home Address 8 Eastbrook Place Dover Kent CT16 1RP 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) 01304 204232 01304 207138 Maureensmith1204@aol.com Mr A Kupendrarajah Ms Maureen Smith Care Home 36 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only – (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) (Maximum number of places - 8) 2. Old age, not falling within any other category (OP) The maximum number of service users to be accommodated is 36. Date of last inspection 19th October 2006 Brief Description of the Service: St. Marys is a large detached property providing residential and dementia care for up to 36 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. The owner has refurbished and extended part of the ground and lower ground floor of the home, including a previously unused area of the building, to create a dementia unit to accommodate up to 8 people with dementia. The unit is secure and carpeting is in a different colour in places throughout the unit for easy identification of different areas i.e. where the floor slopes to create a ramp for wheelchairs. On the ground floor of the unit there is a large comfortable lounge with a small kitchenette to the side for staff to make refreshments. The lounge has large picture windows to the garden. The existing dining room on the lower ground floor has been extended to create a space that will seat a further 8 residents. Access to the garden is on this level also. Residential accommodation is situated over four floors with a passenger lift available for easy access to all floors. There are 28 single bedrooms, all with en-suite toilet and washbasin, telephone, and call bell. Communal areas St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 5 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 is Mrs. Maureen Smith who has been with the home for many years. The current fees for the residential service at the time of the visit are £320 to £399 per week. Fees for the dementia unit can be obtained from the home. 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 reception area. The email address is: maureensmith1204@aol.com St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that the people who use the service experience good quality outcomes. This key inspection was carried out over a period of time and concluded with an unannounced visit to the home between 9.30am and 6.30pm. Residents and staff were spoken to. Observations included interactions between residents and staff. Surveys were sent to the home to distribute to residents, relatives and professionals. Feedback from the people who use the service and relatives is positive. No professional surveys were received back. Various records were viewed during the inspection and a tour of the new dementia unit was made together with a partial tour of the home, including the communal areas and some bedrooms. The dementia unit has just been completed and at the time of this inspection no admissions had been made. The manager is experienced in dementia care and her and the deputy manager have completed an in depth course on the management of dementia care. The manager is also a member of the Alzheimer’s Society. The unit will have a separate dedicated staff team who will also have received or will receive dementia care training. Advice was sought form an independent occupational therapist regarding, wheelchair access, facilities and layout of the unit. It is apparent that the home has worked hard to ensure that the facilities and environment is of a good standard to provide dementia care services. What the service does well: The home continues to provide a good standard of care with an excellent activity programme. Over 75 of the care staff have achieved their NVQ 2 or above this indicates that the residents are receiving care from competent trained care staff. Residents comments: ‘The home is always fresh and clean to an exceedingly high standard. Family and visitors always comment on this’. ‘I am exceptionally well cared for’. ‘I consider St Marys to be above average in all respects’. ‘You can call anytime and staff are always there’. It is really comfortable here, the staff are very kind and the food is good’. ‘Everything runs smoothly in this home’. ‘I have no complaints all of the staff are very St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 7 kind.’ ‘The Manager is wonderful she always comes round the home to speak to everyone’. Relative comment: ‘The home is very inclusive - they try to involve all residents in whatever they are doing and encourage them to join in with activities’. Staff comment: ‘We are able to cater for most of the wishes of our clients. We provide a real home from home experience. I think we provide a service that sometimes goes further than a residential home has to provide. Whatever our clients needs are we try our very best to meet them’. ‘What St Marys does well is meet the needs of the clients as their first priority, the catering is first class and if any service user has special dietary needs this is catered for at the first instance which would give any 5 star hotel a run for its money! The welfare and wellbeing of all clients is foremost concern for all staff and manager who ensure all the clients have all they need for a happy and content stay at St Marys’. ‘The help, support and homely atmosphere here helps service users feel at home able to talk and confide in the carers and management and they feel safe secure and looked after to a very good standard. The residents come first and their wellbeing is the most important thing to us’. ‘The residents are treated very well. It is a friendly environment to live and work in. The food is excellent with plenty of choice. Relatives have ease of access. We hardly ever receive a complaint. It has a good reputation and new staff are chosen with care’. ‘I enjoy working here; although I have only been here for a short period of time I have worked in the care industry most of my life. This home is the best place I have worked. I feel part of a team and know the service we provide is for the service users and not for anyone else. Proud to be here’. ‘We provide very good care for residents, choices, activities and food. There is good communication and good training for all staff.’ What has improved since the last inspection? Medication recording has improved and the home has purchased a refrigerator for cold storage. All staff have received adult protection training and a supervision programme is in place. All radiators are now guarded or have guaranteed low temperature surfaces and the laundry floor has been replaced. St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 8 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Contracts/terms and conditions are in place to ensure residents are aware of their terms of residence. Arrangements are in place to ensure that residents make the right decisions before moving into the home and their needs will be met. Standard 6 does not apply to this home. EVIDENCE: Postal surveys indicate that not all residents have a contract or terms of conditions. The Registered Manager confirms that this has been addressed St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 11 and all residents now have this in place. Residents spoken to at the time of the inspection say they have now received a contract. A full assessment of needs is carried out by the Registered Manager or Deputy Manager prior to admission to the home and residents confirm that this did take place. This information forms part of the care plan and there is evidence of joint assessments/care plans from the placing authority. The home has a waiting list for people wishing to live in the home. St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8,9, and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care, which a resident receives, is based on their individual needs. The principles of respect, dignity and privacy are put into practice. Arrangements are in place to ensure the safe administration of medication and health needs are well supported. EVIDENCE: The care plans cover all aspects of individuals health and social care. The plans record detailed information of health care appointments, including GP visits, District Nurse and if required Community Psychiatric Nurse visits. The plans clearly monitor all health care needs including, personal care, weight, skin St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 13 integrity, behaviours and nutrition. Residents spoken to all say the GP is called promptly and they are well supported with their health needs. There are risk assessments in place and evidence that the plans have been reviewed. However the reviews are not consistently updated. The Registered Manager has a newly appointed Deputy who will be addressing this issue as a matter or urgency to ensure that monthly reviews are carried out therefore a requirement has not been made in this report. Residents are aware of their plans and those spoken to feel the home is meeting their needs. Any equipment required for the relief or the prevention of pressures sores is provided. Moving and handling risk assessments are in place and identify the equipment and hazards but do not contain full details of how to minimise the risk and provide a safe practice of work. Personal care is recorded but sometimes the plans say ‘give assistance’ but information does not clearly say what assistance or level of assistance is required. Staff know the residents and are clear what assistance means to individuals however this needs to be recorded in the plans. A recommendation will be made in this report. Resident comment: ‘The staff do not hesitate to send for the doctor if they feel it necessary’. St Marys staff organise medical appointments for me and also take me to the clinic/dentist etc.’. Medication is mainly supplied by the monitored dosage system and a medication trolley is used when administering the medication. Due to lack of space at times the trolley is left in areas, which are not suitable, and the Registered Manager is going to review this situation to ensure the trolley is left in a safe area. The Registered Manager ensures that audits are carried out and staff are aware of the importance in reporting any gaps that may occur. The Medication Administration Sheets were sampled and those seen had hand written entries countersignatures to reduce the risk of error. Cold storage is now in place and all staff administering medication have received training. The use of creams is identified in the care plans however further information is required to ensure carers are aware of where to apply the cream. A recommendation will be made in this report. All residents spoken to say they are happy that the home deals with their medication. A resident comment: ‘The staff are trained to administer medication and to act in an emergency’. All of the residents spoken to at the time of the inspection and those surveyed feel the staff and management respect their privacy and dignity. Residents confirm that staff always treat them with respect and ensure privacy and dignity is upheld. St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The excellent activity programme provides residents with stimulating and recreational interests to enhance their daily lives. Residents are supported and encouraged to have control over their own routines and lifestyles. Residents receive a well balanced healthy diet to meet their tastes and choices. EVIDENCE: There is a dedicated activities organiser who is qualified to provide armchair aerobics. The home provides, aromatherapy, facials, hand and foot massage, games, story time, cooking, keep fit, knitting, embroidery, bingo and poetry. There is also a book club. On occasions the staff also take the residents out and one confirmed that she had recently visited the local gardens and also watched the carnival. Individual participation of the activities is recorded in the care plans and all residents spoken to say how good the activity St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 15 programme is. They confirm it is their choice whether they join in or not but everything is there if you wish to take part. There are regular church services for all denominations and the home has their own chapel on the ground floor. Residents meetings are held and if able residents are supported to go out on their own. All residents are encouraged to participate in the activities or any event in the home. This standard has been scored as 4, which is standard exceeded (commendable). Resident comment: ‘Activities are very good there is cookery, keep fit, book club, and weekly service in the chapel at St Marys’. Relative comment: The activities are really excellent, one of the main reasons for selecting this home. Spiritual needs: ‘it is good to see all denominations are well catered for’. Visitors are made welcome in the home and residents say they can see them in the lounge, their own bedroom or the quite room. Relatives are offered refreshments or can make their own tea on the small kitchenette units situated by the lounges. Resident’s say they can do what they wish in the home. Residents were observed walking freely round the home and confirm they just leave the lounge if they wish to watch their own television programmes in the bedroom. Discussion was held with one resident who preferred to stay in her room by choice but did go down to the dining room for her meals. All of the residents spoken to in the lounge gave examples of choice with regard to getting up and going to bed, daily life decisions and the activities. They were very complimentary about the choice of meals and said there was always an alternative if they wished. Feedback from residents and relatives is very positive with regard to the choice and standard of the meals being provided. The Chef has been in post for some considerable time and knows the residents likes and dislikes well. He demonstrated his knowledge of any specific dietary requirements for individuals and speaks to all residents daily with regard to their choices. Each day a three-course meal is provided at lunchtime followed by a cooked tea. On Sundays residents are offered wine at lunchtime and in the evening alcoholic or non alcoholic beverages. The majority of the food is home made including cakes for tea. Relative comment: ‘excellent choice of menus’. ‘The food is served very well’. On some days afternoon tea is served which may consist of the cakes or biscuits cooked by the residents at the activity session. St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are confident that their complaints will be listened to and acted on. Arrangements are in place to ensure that residents are protected from abuse. EVIDENCE: The home has a complaints log in place and residents spoken to all say they have no complaints but feel confident that any would be listened to and acted upon. The complaints procedure is on display and the AQAA states that the Manager and Deputy Manager make a point of daily contact with the residents giving them the opportunity to talk about anything in the privacy of their own rooms. This was confirmed by the residents who say that they are always around if you need to speak to them. Resident: ‘The head carer is always available and also the Manager works hard to resolve any need or situation, appointment or visit’. ‘The staff listen to what I have to say and we are always told to raise any issues when they occur and not to wait say for a week before telling anyone’. ‘I have no complaints and the senior carer always listens to me’ St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 17 The majority of staff have received adult protection training and demonstrated their understating of safeguarding. There have been two adult protections alerts since the last inspection the home has responded appropriately and both alerts are now closed. The senior member of staff on duty was very clear with regard to safeguarding protocols and had just covered this in her NVQ 3. St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is comfortable, well maintained and in good decorative order ensuring that residents live in a pleasant clean homely environment. EVIDENCE: A full tour of the new dementia unit was carried out; the bedrooms have spacious en suite facilities. The rooms are decorated and furnished to a high standard. The garden lounge is to be used for communal space and an additional area has been added to the existing dining room. The current dining area is small and service users have mentioned that they have to wait to be supported to move. This is due to the lack of space and the general use of wheelchairs and zimmers. The home acknowledges that the residents have St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 19 a point with regard to the dining room and has introduced a rota so there is a fair system of access to the area. The Registered Manager says that this may be reviewed when dementia service users begin to use the new part of the dining area. The garden is well maintained and a new fence has been erected, the area is safe and accessible for residents who choose to sit and walk in the fresh air. The gardens are well maintained and there is also a covered walkway from the car park to the rear entrance. The laundry floor has been replaced and all of the radiators are now covered. There are infection control measures in place and the home smelled pleasant in all areas seen. Staff have received infection control training. A relative comment: ‘I am more than happy with cleanliness of home’. St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28.29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are receiving care from trained competent staff team, however a review of staffing levels in the afternoon will benefit residents. Arrangements are in place to ensure that residents are receiving care from staff that has been appropriately vetted. EVIDENCE: At the time of the inspection the Registered Manager and Deputy Manager were on duty. There was a senior carer and four carers, two domestics, a chef, kitchen assistant and in the afternoon the activities organiser. The staffing numbers are reduced in the afternoon. Staffing levels are provided on the assessed needs of the residents and staff says that the Manager and Deputy assist with the residents as and when required. There are currently two high dependency residents and with the large areas of the home it is recommended that staff levels be reviewed after 3pm to ensure that there is enough staff on duty to meet the needs of the residents. Residents, a relative and staff have commented that it would be beneficial to increase staffing levels. A recommendation will be made in this report. The Registered Manager says that staffing levels will be reviewed especially with the new St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 21 dementia unit coming into operation. There will be dedicated staff allocated to the new dementia unit. The home also has volunteers to assist with the maintenance and reception duties in the home. Resident comment: ‘There is sometimes a delay in answering routine calls for instance during staff handover. Emergency calls are answered promptly at all times’. The majority of staff have completed their NVQ 2 or above and the home has achieved over 75 of their staff gaining this award. This home has therefore exceeded this standard (commendable) and has received a scoring of 4. Staff files were sampled and contained the relevant documentation to show that staff are appropriately vetted. Files contain CRB (Criminal Record Bureau) and the Protection of Vulnerable Adult checks, together with proof of identification and two satisfactory written references. Staff interviews are recorded and interview notes kept. These records are not fully consistent and it is recommended that the Registered Manager audits all staff files to ensure that all documentation is in place. The home has a training matrix in place and an ongoing training programme. A new system has been developed to ensure that staff training is updated when required. The majority of staff have received the mandatory training and there is an on going programme to ensure that staff are able to develop their skills and knowledge. This month further fire and first aid training is being provided. There is also an ongoing programme for dementia training and all staff will be attending mental capacity training towards the end of the year. A senior member of staff confirms that she completed her induction and now assists in the supervision of new recruits to help them through their induction period. St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a well managed home which is run in their best interests. Arrangements are in place to ensure the people who use the service financial interests are protected. Residents and staff are protected by the arrangements in place to minimise risk and promote health and safety. EVIDENCE: St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 23 Residents and staff are very complimentary about the management team. They have confidence in her ability to run the home efficiently. She is qualified and experienced. Since the last inspection a Deputy Manager and three senior carers have been appointed ensuring there are clear lines of accountability. The Registered Manager is now looking forward to providing dementia care and new admissions will be taken in the home from 14th July 2008. A quality assurance programme is in place and this includes questionnaires being sent to residents, relatives, Doctors, and District Nurses. These were sent out in July and are now being returned to the home to be summarised. The Registered Manager evaluates the results and will implement any action if required. The results of the quality assurance will then be summarised in the home’s newsletter. Residents say they have meetings and the owner ensures that monthly visits are made to the home to monitor the service being provided. From speaking to the residents it is evident that they feel confident in providing feedback to the manager. Resident comment: ‘We do have residents meetings to talk about things, we have also recently been sent a questionnaire about the service, I have completed this’. There are some residents who are supported with their finances and the Registered Manager and Deputy deal with these issues. Other residents are supported with their finances by their relatives or solicitor. There are secure facilities and effective recording systems in place to ensure that all transactions are recorded. The Registered Manager and Deputy ensure that staff receive supervision. The staff confirms supervision is taking place and staff feel supported by the management team. The AQAA states that all equipment has been serviced and maintenance and safety checks are up to date. All mandatory training is up to date and ongoing. The fire book is in good order and risk assessments are in place. Residents confirm the fire alarm is tested weekly and there is clear evidence of staff on duty when fire drills are carried out. The induction training programme is linked to Skills for Care. St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 x x x x x 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 3 x 3 St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. Refer to Standard OP7 Good Practice Recommendations Risk assessments and personal care information in service user plans require further detail to ensure that staff have clear guidelines and provide a safe practice of work. The home needs to provide further information of where to administer creams. To review staffing levels during late afternoon and evening. 2. 3. OP9 OP27 St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Mary`s Home DS0000064080.V367031.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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