Inspection on 01/02/07 for St Mary`s House

This inspection was carried out on 1st February 2007.

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 House 21/01/09

St Mary`s House 01/03/06

St Mary`s House 18/10/05

St Mary`s House 09/12/04

St Mary`s House 29/06/04

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 House 38/39 Preston Park Avenue Brighton East Sussex BN1 6HG Lead Inspector Jennie Williams Key Unannounced Inspection 1st February 2007 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Mary`s House DS0000014243.V324108.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 House DS0000014243.V324108.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary`s House Address 38/39 Preston Park Avenue Brighton East Sussex BN1 6HG 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) 01273 556035 01273 556035 stmaryshousebrighton@tiscali.co.uk The Grace and Compassion Benedictines Maria Magdalene Antony Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places St Mary`s House DS0000014243.V324108.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users must be older people aged sixty five (65) years or over on admission. That no more than twenty two (22) service users are accommodated. Date of last inspection Brief Description of the Service: St Mary’s House is a residential home registered to provide care and accommodation for up to twenty-two older people. The home is owned and run by the Benedictine Sisters of our lady of Grace and Compassion. No nursing care is provided at this home. District nurses will provide nursing input for those residents requiring this. The home is comprised of two detached properties, which have been joined together for its current use. It is situated within walking distance of local shops and bus routes into Brighton and overlooks Preston Park. All rooms are for single occupancy and are located over three floors. All rooms are provided with en suite facilities. There is passenger shaft lift available to assist residents in accessing all areas of the home. There is a good-sized lounge room and dining room for residents to use. There is a chapel on site and a large accessible garden at the rear of the home. There are five communal toilets located throughout the home and five assisted bathing facilities; four assisted baths and one wheel in shower. There is limited parking available at the home, however free parking is available in adjacent streets. There are six rooms available at the home that are designated for visitors that may require accommodation when visiting. Weekly fees range from £361 to £451 per week. There are additional fees; hairdressing (£8 to £25), chiropody (£6 to £25), newspapers/magazines and personal toiletries (at cost). This information was provided to the CSCI on the 20 December 2006. Prospective residents find out about the home through social services referrals, word of mouth and from themselves/relatives living in the area and through the church. St Mary`s House DS0000014243.V324108.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act (as amended), uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at St Mary’s House will be referred to as ‘residents’. This unannounced key inspection took place over approximately eight and a quarter hours on the 01 February 2007. Ten residents, of both genders and over the age of 65 years, were spoken with during the inspection. One resident did not wish to be involved in the process and this was respected. Ten resident surveys were sent to the home prior to inspection, of which seven were returned. Two care plans were looked at in detail and specific areas of care needs were looked at in three other care plans. The Registered Manager, deputy manager and seven care staff were spoken with. Four staff files were inspected. Five GP comment cards sent out prior to inspection were all returned. Ten relative/visitors comment cards were sent to the home of which seven were returned. A survey was sent to a care manager, which was returned. A pre-inspection questionnaire was received prior to the inspection. A tour of the environment was provided and some individual rooms were viewed. Medication procedures were inspected. The quality assurance system was discussed and complaint records were viewed. Previous requirements and recommendations at the home were assessed to ensure compliance. The Inspector ate lunch with the residents. No other health and safety records were viewed as this information has been provided in the pre-inspection questionnaire. There were 20 residents residing at the home on the day of the inspection. What the service does well: Residents were complimentary about the staff working at the home and felt that their personal care needs were being met. Prospective residents are provided with opportunities to visit the home prior to moving in to ensure the home will meet their needs. Residents felt that their privacy and dignity are respected. All residents residing at the home remain generally independent and require only some assistance with their personal care needs. Visitors are welcomed at the home and residents may receive visitors in private. Residents were complimentary about the provision of food at the home. Residents are provided with regular fulfilling activities. Residents feel comfortable and know how to make a complaint and feel that they will be St Mary`s House DS0000014243.V324108.R01.S.doc Version 5.2 Page 6 listened to. Residents are happy with their individual rooms and are able to personalise them. Staff receive training appropriate to their roles to ensure their safety and that residents needs continue to be met. Residents benefit from a low turnover of staff, ensuring continuity of care is provided. Residents and staff benefit from supportive and approachable management within the home. 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. The summary of this inspection report can be made available in other formats on request. St Mary`s House DS0000014243.V324108.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Mary`s House DS0000014243.V324108.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4, 5 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Fully completing the pre admission assessment will better ensure that only those residents whose needs can be met will be admitted. Prospective residents are provided with an opportunity to visit the home prior to admission. Intermediate care is not provided at the home. EVIDENCE: All prospective residents are assessed prior to admission. Information is obtained from other health professionals wherever applicable. The pre admission assessments viewed were not fully completed. Information needs to be expanded to evidence that all needs can be met with the services and facilities provided at the home. One resident came from a different county and no assessment had been undertaken by the home. The resident had completed the form themselves. The Registered Manager said that a registered nurse from the previous establishment would go through the form St Mary`s House DS0000014243.V324108.R01.S.doc Version 5.2 Page 9 with the resident. The home had not followed this up. Prospective residents complete the assessment form themselves and a representative from the home will go through the assessment form with them. The Registered Manager confirmed that there was no one residing at the home from any minor ethnic community or social or cultural groups with any specific needs or preferences. The home is run by the Benedictine Sisters of our Lady of Grace and Compassion, however residents from any religious denomination may be admitted to the home. There was evidence that the home meets the religious needs of residents. There is a chapel on site and anyone is able to use this facility, regardless of their faith/belief. Staff individually and collectively have the skills to deliver the services and care that the home offers to provide. Residents/relatives are provided with an opportunity to visit the home prior to admission. The majority of residents spoken with confirmed that they or a relative had visited the home prior to admission. All resident surveys received demonstrated that they received enough information about the home before they moved in so they could decide if it was the right place for them. One comment written was ‘ I made an excellent decision when I decided to come here.’ The home does not have dedicated accommodation to provide intermediate care. Respite care is provided if there is a spare place available. St Mary`s House DS0000014243.V324108.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. 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. Residents needs are being met at the home, however clearer information needs to be provided in the care plans to ensure staff are aware of all the assessed needs of an individual. Residents are safeguarded by the medication procedures in place. EVIDENCE: With one resident’s permission, the Inspector viewed their care plan with them. The resident confirmed that most of the information contained in the care plan was accurate. The resident identified one problem on the care plan that she did not feel was an issue any more in relation to her needs. This was discussed with the Registered Manager who will discuss this with the individual. Care plans read provided clear information for staff on problems identified for individuals, however a clear picture of all the individuals’ needs was unable to be obtained. No information was provided regarding an individual’s bathing St Mary`s House DS0000014243.V324108.R01.S.doc Version 5.2 Page 11 preferences, likes/dislikes in food, social needs etc. Support being provided by the district nurses was not reflected in another individual’s care plan. Guidance for staff should provide information on all the assessed needs as stated in Standard 3.3. Care plans were seen to be reviewed monthly and are drawn up with the involvement of the individual, however on discussion with some residents they confirmed that they are not familiar with their care plans. All relative/visitor comment cards received demonstrated that they are kept informed of important matters affecting their relative/friend and are consulted about their care. Residents did confirm that staff discuss their care with them. A life history is currently being obtained for all residents, with them and their relatives being involved in this process. Residents residing at the home are fairly independent. The home undertakes a falls risk assessment for each individual. Residents spoken with all confirmed that their personal care needs are being met at the home. Of the residents that were asked, all confirmed that staff encourage them to remain as independent as they are able. All resident surveys received demonstrate that they receive the care and medical support they need. Staff and GP comment cards all confirmed that management take appropriate action when the needs of a resident can no longer be managed at the home. All GP comment cards showed that staff demonstrate a clear understanding of the care needs of residents and that any specialist advice given is incorporated into the resident’s plan of care. Some comments written by the GP’s were ‘..an excellent level of care at St Mary’s House, very professional and caring environment’, ‘residents are well cared for’, ‘super quality care provided’, and ‘… one of the few homes I would go into for my family’. The Registered Manager confirmed that there are no residents with pressure sores and the home has access to pressure relieving equipment when needed. Residents observed to be wearing glasses and hearing aids all confirmed that eyesight and hearing tests are arranged when required. The deputy manager confirmed that there are policies and procedures in place for all aspects dealing with medication. The content of these were not read. Medication Administration Record (MAR) charts viewed demonstrated that medication is being signed for at the time of administration. The home is in the process of taking photographs of the residents to place on the MAR charts. It was confirmed that all staff administering medicines have received training and are supervised initially. There are records kept of incoming and outgoing medication. It is recommended as good practice that all hand written prescriptions are double signed by two staff who are medication trained. Residents are provided with an opportunity to self medicate, based on a risk assessment being undertaken. It is recommended that guidance be St Mary`s House DS0000014243.V324108.R01.S.doc Version 5.2 Page 12 incorporated into an individual’s care plan regarding the level of selfmedication. All residents spoken with confirmed that their privacy and dignity are respected. It was confirmed by residents and observed by the Inspector that staff knock on residents’ room doors prior to entering. Staff were observed to have a good professional rapport with the residents and were heard to be calling them by their preferred term of address. Written comments from staff members were ‘… I have never experienced such genuine respect for the individual as I have found at St Mary’s’ and ‘I feel we look after the clients with respect, love, dignity and they come first in all we do. We treat each one accordingly to their needs individually.’ St Mary`s House DS0000014243.V324108.R01.S.doc Version 5.2 Page 13 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 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ lifestyle within the home is their own choice and residents are provided with sufficient stimulation to fulfil their interests and needs. Residents’ choice and preferences are catered for with meals. EVIDENCE: Residents spoken with confirmed that there were suitable activities provided at the home. All spoke positively about the arrangements at Christmas. Staff from foreign countries dressed in their traditional clothing and performed songs and dances from their home countries. Residents stated that they really enjoyed this performance. Activities are provided by the staff on duty. Outside entertainers regularly visit the home. Residents from St Mary’s House also participate in activities with residents from another care home within the area. Four resident surveys demonstrated that there are always activities arranged by the home that they can take part in, three stated there are usually activities arranged. Residents were participating in gentle exercises on the day of the inspection. St Mary`s House DS0000014243.V324108.R01.S.doc Version 5.2 Page 14 Residents spoken with confirmed that their lifestyle within the home is their choice. They choose what to wear and when to get up and go to bed etc. Residents are encouraged to bring in personal possessions with them to personalise their own rooms. Residents are able to go into the community unescorted whenever they wish. Restrictions are only imposed if a risk assessment identifies that it is unsafe for the individual to go out independently. One written comment from a staff member was ‘ St Mary’s is at the centre of the Roman Catholic community in the Preston Park area and has excellent links with the wider community, which is highly beneficial to the residents who do not feel removed from their former lifestyle.’ There are no restrictions for visitors. There is a visitor’s book located at the entrance of the home that all people must sign when entering and leaving the building. All visitor/relative comment cards stated that they are welcomed in the home at any time and are able to have visits in private. Some written comments received were ‘ the care my mother receives is excellent’ and ‘excellent care from every department. We could not have asked for a better residential home.’ The Inspector enjoyed a roast dinner with the residents for lunch. Residents were observed to be enjoying the meal and lunchtime appeared to be unhurried. Staff were observed to be nearby to offer discreet assistance should anyone require it. Five resident surveys showed that they always like the meals, one usually like the meals. Written comments were ‘ I think the meals are very good. They will always give you something different if you want it’ and ‘if there is something that I am not allowed to eat the staff are good at giving alternatives’. Residents spoken with were complimentary about the food being provided at the home and confirmed that alternatives are provided if they do not like what is on offer. St Mary`s House DS0000014243.V324108.R01.S.doc Version 5.2 Page 15 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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are dealt with appropriately, reassuring those involved that they are being listened to and that action will be taken, if necessary. Protection of Vulnerable Adults procedures ensure residents are safeguarded. EVIDENCE: The home has a complaints procedure that all involved with the home has access to. No complaints have been made directly to the CSCI or any made directly to the home since the last inspection. Residents’ surveys received demonstrated that most residents know who to speak to if they are not happy about something and know how to make a complaint. Of the residents that were asked, all confirmed that they know who to speak to if they had any concerns and feel comfortable making complaints and know that action will be taken if necessary. There is a complaint/suggestion box in the dining room. Six of the relative/visitor surveys received demonstrated that they are aware of the home’s complaint procedure and have never had to make a complaint. St Mary`s House DS0000014243.V324108.R01.S.doc Version 5.2 Page 16 The Registered Manager confirmed that there is a Safeguarding Adult procedure. The content of this was not read. There have been no allegations of abuse made since the last inspection Staff spoken with confirmed that they are familiar with Safeguarding Adult procedures and have undertaken training. All staff surveys received demonstrated that they are aware of adult protection procedures and are aware what will happen to them is a resident or colleague accuses them of anything. St Mary`s House DS0000014243.V324108.R01.S.doc Version 5.2 Page 17 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and homely environment and are provided with comfortable indoor and outdoor communal facilities. EVIDENCE: St Mary’s House is two homes that have been joined together for its current purpose. Rooms are located over three floors and there is a passenger shaft lift available to assist residents to access all areas of the home. There are grab rails placed throughout the home in areas where residents may require some assistance with mobilisation. Residents confirmed that they were happy with their rooms, which were observed to be personalised to reflect the personality and character of the St Mary`s House DS0000014243.V324108.R01.S.doc Version 5.2 Page 18 individual. Residents spoken with confirmed that they were able to bring personal items with them when moving into the home. Hot water taps were observed to be regulated and windows were noted to be restricted. The pre-inspection questionnaire demonstrates that there are policies and procedures in place for infection control. The content of these were not read. The Inspector informed the Registered Manager of areas where cleaning could be improved. This included under the bath hoist seats and lace curtains in individual rooms. No requirement has been made in respect of this as the Registered Manager confirmed she will ensure these areas are addressed. The home was free from offensive odours on the day of the inspection. St Mary`s House DS0000014243.V324108.R01.S.doc Version 5.2 Page 19 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being met with the number and skill mix of staff on duty and are safeguarded by the recruitment procedures. EVIDENCE: Residents were very complimentary about the staff working at the home. Staff spoken with confirmed that they enjoy working at the home. A comment received by a staff member was ‘ There is phenomenal, good teamwork.’ All residents and staff spoken with confirmed that there were sufficient numbers of staff on duty at all times. All relative/visitor comment cards demonstrate that in their opinion there are always sufficient numbers of staff on duty. The Registered Manager confirmed that there are six to seven staff working in the mornings, three staff between 2.00pm and 5.00 pm, six to seven staff in the evening, one waking carer at night with two carers on call. One written comment from a visiting health professional stated ‘There has been improvement since the CSCI inspection – a new rota schedule has been produced to cover the times when the nuns go for prayer – therefore ensuring staff availability at all times.’ Residents benefit from a low turnover of staff, ensuring continuity of care is provided. St Mary`s House DS0000014243.V324108.R01.S.doc Version 5.2 Page 20 Staff files viewed demonstrated that enhanced Criminal Record Bureau (CRB) checks and references are obtained prior to an individual commencing employment. There were some minor shortfalls noted on the day of the inspection. These were discussed with the Registered Manager who will address these issues. Further information was provided to the Inspector following the inspection to evidence that overseas staff had appropriate visas to be working in the United Kingdom. There are 15 care staff employed at the home, of which 14 have obtained National Vocation Qualification (NVQ) level 2 or above. One staff member is still completing these studies. This is above the recommended 50 ratio of NVQ level 2 trained staff. Staff spoken with confirmed that they are kept up to date with all mandatory training and stated that there was good training opportunities. One new member of staff informed the Inspector that they felt there was a good induction process in place. Copies of training certificates were kept within an individuals staff file. St Mary`s House DS0000014243.V324108.R01.S.doc Version 5.2 Page 21 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally run in the best interest of residents. Residents’ financial interests are safeguarded. The health, safety and welfare of residents and staff are promoted and protected so far as is reasonably practicable. EVIDENCE: Staff spoken with were very complimentary about the Registered Manager and find her approachable, very understanding and supportive. The Registered Manager is registered with the CSCI and staff commented that the Registered Manager ‘adapted very quickly’. They were also complimentary about the deputy manager in post. The Registered Manager has worked for approximately 18 years with the elderly and has 6 years management St Mary`s House DS0000014243.V324108.R01.S.doc Version 5.2 Page 22 experience in various homes. She has undertaken the Registered Manager Award in care in 2003. Written comments received from staff included; ‘ I find I have lots of support from my manager and deputy manager and if I have any problems they are very helpful’ and ‘the team work and communication is excellent’. The quality assurance system was discussed with the Registered Manager. She confirmed that every year comment cards are sent to residents, relatives and other health professionals. Staff meetings are held every couple of months and resident meetings are held every three months. Minutes of these meetings are available for visitors/relatives to read. The Registered Manager confirmed that conclusions are drawn from the results of the surveys and action taken if necessary. The home is not an appointee for any resident. The home holds personal allowances for some residents. The Registered Manager confirmed that most residents are able to manage their own finances or have family members assisting them. There are clear records maintained of residents’ monies and receipts are obtained for any financial transactions. The monies checked evidenced that there are clear records of financial transactions being maintained. The Registered Manager and staff spoken with all confirmed that all staff are kept up to date with mandatory training. The pre-inspection questionnaire demonstrates that fire alarms are tested weekly. Staff spoken with confirmed that they had a fire drill about six months prior to the inspection. No health and safety records were inspected on this occasion as this information has been provided in the pre-inspection questionnaire. St Mary`s House DS0000014243.V324108.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 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 X X 3 St Mary`s House DS0000014243.V324108.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP3 OP7 Regulation 14 15 Requirement That a suitably trained person completes all pre admission assessments. That care plans provide clear information on the health, personal and social needs of service users. Timescale for action 30/04/07 30/04/07 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 OP9 OP9 Good Practice Recommendations That all hand written prescriptions are double signed by two staff who are medication trained. That guidance be incorporated into an individual’s care plan regarding the level of self-medication. St Mary`s House DS0000014243.V324108.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Local 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 House DS0000014243.V324108.R01.S.doc Version 5.2 Page 26 - 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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