Inspection on 22/08/06 for St Mary`s House

This inspection was carried out on 22nd August 2006.

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

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

Other inspections for this house

St Mary`s House 22/11/05

St Mary`s House 21/06/05

St Mary`s House 29/11/04

St Mary`s House 10/06/04

St Mary`s House 08/12/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Foxley Lane (121a)

Red Court Nursing Home

Spinney (The)

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 71 Ormond Avenue Hampton Middlesex TW12 2RT Lead Inspector Sharon Newman Unannounced Inspection 22nd August 2006 10:00 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 DS0000017391.V308581.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 DS0000017391.V308581.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary`s House Address 71 Ormond Avenue Hampton Middlesex TW12 2RT 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 8979 2847 stmaryshouse@dial.pipex.com Ms Sylvia Warren Mrs Sylvia Warren Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24), Sensory impairment (24) of places St Mary`s House DS0000017391.V308581.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd November 2005 Brief Description of the Service: St Marys House is registered to provide accommodation for 24 older persons. The home is owned and managed by Mrs. S Warren who takes a pro-active dedicated and hands-on approach to care. Many of the staff have worked at the home for a number of years. The home is situated in an affluent residential road which is tree-lined and attractive. The building is a substantial (extended), detached property with a well-kept garden. Fees range from £515.00 to 418.20 per week. St Mary`s House DS0000017391.V308581.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted on the 22nd August 2006 by one regulation inspector. The manager and three staff members were spoken to during the visit. Records examined included care planning documentation, health and safety information and medication records. A tour was also taken of the premises. The manager was very helpful throughout the visit and remains genuinely committed to her work and to the residents. Surveys were left at the home for relatives, residents and staff to complete and return. Some surveys were sent out to health and social care professionals. None were returned prior to completion of this report. Many residents were spoken to and they were very complimentary about life at the home. One resident wrote in a letter ‘I guarantee you will not find a better place’ another commented ‘I am so happy here.’ What the service does well: What has improved since the last inspection? Care plans and risk assessments are now reviewed monthly and a risk assessment was in place for a resident who needs bed rail equipment. St Mary`s House DS0000017391.V308581.R01.S.doc Version 5.2 Page 6 An assessment of the premises has been carried out by an occupational therapist to help ensure that the environment meets the needs of the residents. All cleaning fluids and other COSHH substances were seen to be locked away and a five yearly electrical check has now been obtained to help ensure that residents and staff are not placed at risk. 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 House DS0000017391.V308581.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 DS0000017391.V308581.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Good information is available to help residents decide if this home can meet their needs. Assessments of need are in place for all residents which helps detailed care plans to develop from this documentation. Intermediate care is not offered at this home. EVIDENCE: An informative ‘Service Users Guide’ is in place to help residents and relatives decide if this home can meet their needs. Assessments were in place in the residents’ files that were looked at. This enables the manager to decide if this home is suitable for the prospective resident. She discussed the issues involved when carrying out assessments. She said that sometimes all the residents’ needs may not be apparent at the first assessment and that this assessment process may take place over a few weeks. St Mary`s House DS0000017391.V308581.R01.S.doc Version 5.2 Page 9 She reported that sometimes situations can develop where it becomes apparent that the home may not be the best environment for a particular resident. She said that she works closely with the family to ensure that any resident in this position is reassessed and they are then helped to move to another more suitable environment where their needs can be met. She demonstrated an understanding of the complex needs of the residents and of ensuring those admitted to the home will be happy here and that they will get on well with the other residents. The manager reported that she is very serious about ensuring that residents’ needs are met. She showed the inspector a letter she had written to the local Primary Care Trust asking for assistance in ensuring that a residents health needs are met. This correspondence demonstrates that she values resident’s needs and that she tries to ensure that their health care needs are met. Evidence seen at the time of inspection showed that the home requests specialist input and assessments for residents from GP’s, Occupational Therapists and District Nurses. One the day of inspection the manager had accompanied a resident to a healthcare appointment to offer support and to ensure that any follow-up care would be understood and then passed on to staff. This helps to ensure that residents’ ongoing needs are met. A new resident was spoken to and they reported that they were ‘very happy’ with their choice of home. They said they had ‘lived at another home before coming here and this home was much better.’ They commented that the staff were ‘very kind here’ and ‘we are looked after well.’ They said that they choose when to get up in the morning and when to go to bed. Another resident wrote that ‘all our clothes are washed and beautifully ironed and returned in two days.’ Contracts were in place in all the residents’ files that were seen during the inspection visit. St Mary`s House DS0000017391.V308581.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Resident’s health needs are met and they are treated with respect by staff. The manager takes the health needs of the residents seriously and takes necessary action to ensure they are met. Measures are in place to ensure the safe recording, administration and storage of medication. EVIDENCE: Four care plans were looked at and were seen to have been regularly reviewed by staff to help ensure that residents changing needs are documented. A risk assessment was in place for a resident who requires bed rail equipment. A discussion took place about the need to ensure that the residents and relatives wishes are documented in relation to this and appropriate healthcare advice sought from a professional such as an occupational therapist or district nurse. The manager said she would address this. Evidence was seen in care plans of input from health care professionals including occupational therapists, GP’s, community nurses and social workers. St Mary`s House DS0000017391.V308581.R01.S.doc Version 5.2 Page 11 A resident commented in a letter that the manager ‘will take any of us for hospital appointments, eye tests etc and she comes in with us. Whatever you ask her to do she tries her best.’ When residents’ needs increase and nursing care is needed, the home works together with the local social services and health professionals from the Primary Care trust to help keep those residents who wish to stay at the home here. This helps to provide continuity of care and respects those residents’ wishes. The manager reported that District Nurses visit the home regularly to provide support to those residents requiring more care. Specialist equipment such as pressure relieving mattresses and hoists are used to help ensure that residents increasing needs are met. She said that the GP visits weekly and provides good support to the home. Medication was stored securely within a locked cupboard on the day of inspection and is provided in a monitored dosage system. The medication administration records were in good order and no omissions in recording were seen. All residents with allergies had these recorded clearly to help ensure the safety of the residents. Those residents with no known allergies did not have this recorded and it was discussed with the manager that where residents do not have an allergy then this should also be recorded on the MAR sheets. There are comprehensive medication policies in place at the home, including one for homely remedies, disposal of medicines and a self-medication policy. Staff must undertake training and are supervised before they can give out medication to residents. Residents were observed to be treated with kindness and dignity by staff. Staff spoken to had a good knowledge of their needs. Residents were seen to be able to choose to go to their bedrooms whenever they wished to watch television, listen to music, read or rest. One resident reported that they preferred to spend a lot of time in their room as they valued their privacy and that this choice was respected. St Mary`s House DS0000017391.V308581.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Activity provision is good and residents are encouraged to participate in activities. They are also encouraged to maintain contact with family and friends. Relatives are made to feel welcome at this home. Residents are offered a choice of nutritious meals in a pleasant, homely setting. EVIDENCE: A resident reported that they enjoyed participating in the evening activities that were on offer each night. They said that this included bingo, armchair exercises, quizzes and staff members reading them poetry. Residents were observed participating in a quiz with a staff member. One resident reported that they were ‘very much enjoying teaching bridge to another resident.’ Throughout the day residents were seen to choose what they wished to do. Some residents chose to sit with others and chat or some read books or newspapers in the lounge area. Others went to their rooms to watch television or read. A list of the residents and the newspapers they prefer to read was displayed in the office and residents said that their newspaper was delivered daily. One resident reported that they enjoyed having so much to choose from. They said they liked watching television and videos, listening to music, reading St Mary`s House DS0000017391.V308581.R01.S.doc Version 5.2 Page 13 their newspaper, participating in the evening activities and doing needlecraft. One resident wrote that the home provides ‘entertainers, music, pianists’ which is ‘followed by a delicious buffet supper.’ They also commented that a church service is held once a month for those who wish to take part. Residents commented that a few outings had been arranged recently to places such as Littlehampton, Kew Gardens, Kensington Palace and a boat trip. The manager reported that she enjoyed arranging these trips and usually drove the minibus. The home is starting to compile residents ‘Memories Books.’ The ones that have been compiled so far are very informative and contain information about their families, schooldays, holidays, career, marriage and war memories. These are helpful and allow staff to build up a picture of the residents as individuals. The menus are rotated on an eight-weekly basis and residents are given menus to choose from during the week. They are asked for their opinion and what they would like to add to the menu. The residents spoken to said that they are offered a choice at mealtimes and that if there is nothing that they like then they are offered an alternative. The tables in the dining room were set for lunch with attractive tablecloths and linen napkins. Residents were seen to eat in a relaxed atmosphere chatting to each other. Staff members helped those residents who needed assistance discreetly and with dignity. Residents are offered a choice of meals and vegetarian and health needs such as diabetes are catered for. A resident reported that the food was ‘nutritious’ and that you always have ‘plenty.’ A staff member said that the food was ‘good and freshly cooked.’ One resident wrote ‘we have delicious home cooked meals and we always use bone china crockery.’ They also commented ‘we can have second helpings if we wish and we can have family and friends to any meal.’ One resident said ‘the food is lovely and you always have a choice.’ Another commented that ‘you can have meals in your room when you wish.’ Drinks and snacks are offered throughout the day, tea or coffee is offered in the morning with breakfast, also midmorning and after lunch. Drinks are also offered with all meals and before going to bed. One resident said that they enjoyed having ‘a glass of Guinness’ before they went to bed. Another resident wrote that they ‘have wine at dinner time and a cake on our birthdays’ and also ‘a glass of sherry before every Sunday dinner.’ St Mary`s House DS0000017391.V308581.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Policies and procedures are in place to help protect residents from abuse, however all staff need to undertake training in abuse awareness to ensure that residents are not placed at risk. EVIDENCE: The home follows the London Borough of Richmond’s’ Protection of Vulnerable Adults policy and a copy of these procedures was available at the home. Staff spoken to had a good knowledge about this area and the many different forms of abuse. The manager reported that this type of behaviour would never be tolerated at this home and would be reported immediately. A whistle blowing policy is also available at the home. Staff members spoken to had a very good awareness of whistle blowing and it’s importance in maintaining good practice at work. The manager reported that many staff are up-to-date with training in abuse awareness. However, not all members of staff are up-to-date in this area and this needs to be put in place. The manager reported that she was aware that she could send staff on the London Borough of Richmond’s protection of vulnerable adults training and that she was looking into this. It is also recognised that the manager has devised a new induction programme for new staff and this has a detailed section about abuse awareness. St Mary`s House DS0000017391.V308581.R01.S.doc Version 5.2 Page 15 A complaints log is in place at the home and no formal complaints have been received. Throughout the inspection visit many residents said if they had any issues they would raise them with the manager and that they knew they would be rectified immediately. A file is also kept at the home of the compliments given by relatives and health professionals. A letter has recently been received by the commission for social care inspection from a resident at the home. It is very complimentary about life at the home. St Mary`s House DS0000017391.V308581.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents live in a homely and attractive environment with access to a beautiful and well-maintained garden. The bedrooms are well personalised and comfortable. However there are many areas within the home, which require redecoration and this, lets the general standard of the environment down. The home is clean and hygienic. EVIDENCE: There is a large through lounge, which is divided into two different areas. These are homely and comfortable. They contain comfortable armchairs, bookcases, plants and fish tanks and this helps to create a relaxing atmosphere. The conservatory part of the lounge leads out to an attractive, large well-maintained garden which contains mature shrubs and trees. The dining area has four large tables and is clean and pleasant. The home is clean and hygienic. A resident commented that the home ‘is very clean.’ St Mary`s House DS0000017391.V308581.R01.S.doc Version 5.2 Page 17 The manager reported a professional assessment of the premises by an occupational therapist has now been obtained. This report was available at the home on the day of inspection. Many of the residents said that they liked their bedrooms and those seen were personalised to individual taste. Many residents have their own furniture and belongings in their rooms. Some maintenance issues were identified at the time of inspection. In the dining room there were some areas of scuffed and marked paintwork particularly around the lift entrance. The carpet in this room was seen to be marked, stained and frayed in places. In the lounge there were areas of cracked paintwork on the ceiling. In some of the bedrooms there were areas of cracked and marked paintwork and cracks down the walls. Stained and marked carpets were also seen in some of the bedrooms. In one of the bathrooms the side of the bath was cracked and will need repair/replacing. In the area outside this bathroom the wallpaper was peeling in many areas, the ceiling was stained and many of the skirting boards were scuffed in areas. The linoleum in the top floor bathroom was marked and stained. All these areas require redecoration. It is acknowledge that the home has begun a process of redecoration to some areas of the home and the manager reported that she is well aware that many areas require attention and will address this issue. St Mary`s House DS0000017391.V308581.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Staff are enthusiastic and caring and have a good knowledge of resident’s needs. Staff training has improved at the home and this can help staff to meet the needs of the residents. Pre-employment information needs to be obtained before staff start work at the home to ensure that residents are not placed at risk. EVIDENCE: A staff member said that they enjoyed working here as ‘the home puts residents first.’ They said they felt that the home was a ‘supportive environment’ in which to work and that it ‘offered good quality care.’ Another staff member reported that they ‘loved working here’ and all the staff were ‘caring and friendly’. Staff were observed to be kind and caring toward the residents and they had a good knowledge of their needs, likes and dislikes. Feedback from residents was positive about the staff. One said that ‘the staff are nice’ another said ‘they will do anything for you.’ Another resident commented that ‘all the staff are kind.’ Inadequacies were identified in the staff recruitment files that could potentially place residents at risk. Only one reference was in place in two files seen and St Mary`s House DS0000017391.V308581.R01.S.doc Version 5.2 Page 19 the Criminal Record Bureau (CRB) checks had been obtained from another employer. Two references must be in place for all staff and satisfactory CRB checks must be obtained to help to ensure that residents are not placed at risk. A discussion took place with the manager about trying to organise regular staff meetings for staff to help ensure that they are up-to-date with all events at the home and to pass on ideas and information. Staff training has improved and most staff are up-to-date in mandatory areas such as first aid and food hygiene. Some staff still need to attend training in moving and handling and the manager said this was being organised. Two members of staff are NVQ assessors which means that they can assess other staff in the home who are undertaking NVQ qualifications in care. A staff member reported that what they liked about the home was that it was ‘not like an institution’ and that it was ‘family oriented.’ St Mary`s House DS0000017391.V308581.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The manager continues to demonstrate open and inclusive management style that benefits the home as staff and residents find her approachable. She continues to provide clear direction and leadership within this home and is committed to maintaining high standards of care for the residents and ensuring it is run in their best interests. EVIDENCE: The manager is experienced and has the NVQ Level 4 and Registered Managers Award. Feedback about her from staff and residents was positive. One resident said ‘the manager is lovely and can’t do too much for you’ another said ‘she is wonderful.’ Another commented ‘she is absolutely wonderful.’ One resident wrote ‘She’s a great lady.’ They also commented that she ‘is so kind and caring St Mary`s House DS0000017391.V308581.R01.S.doc Version 5.2 Page 21 that I think she ought to have an award.’ All staff spoken too said that she was approachable and supportive and puts the residents first. She was observed to have a good rapport with the residents and she spoke about them in a caring manner. Evidence was seen to demonstrate that the home has tried to obtain the views of residents in questionnaires. The Manager said that she aims to conduct a yearly quality assurance programme to seek the views of residents and their relatives. Although staff reported that they do have one-to-one supervision and feel well supported there was not enough evidence to suggest that staff supervision is taking place regularly. This should be put in place and be fully documented to ensure that staff receive the support and direction they need to carry out their roles. It is recognised that the manager is trying to address this issue. Residents spoken to said they were happy with the management of their finances. The manager reported that resident’s money is not pooled and they all have separate accounts. Up-to-date certificates were in place for portable appliance testing, the five yearly electrical wiring check, legionella and gas safety. This helps to ensure the safety of staff and residents. A resident commented ‘I feel so lucky to be here, we are well looked after.’ They added that they wanted to ‘say a big thank you to all the staff.’ St Mary`s House DS0000017391.V308581.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 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 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 2 X 3 St Mary`s House DS0000017391.V308581.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP18 Regulation 13 (6) Requirement The registered person must ensure that all staff receive upto-date training in the area of abuse awareness and the protection of vulnerable adults. The registered person must ensure that the maintenance issues outlined in Standard 19 of this report are addressed. Previous timescale of 01/09/05 and 01/02/06 not fully met). The registered person must ensure that staff files contain all the information required in Schedule 4 of the Care Homes Regulations 2001. The registered person should ensure that all mandatory staff training is up-to-date. This is in particular regard to moving and handling. The registered person must ensure that one-to-one staff supervision takes place at least six times a year. Pro-rata for part time staff. Previous timescale of 01/02/06 not met. Timescale for action 01/11/06 2 OP19 23(2)(b) (b) 01/04/07 3 OP29 19 (4) 01/10/06 4 OP30 18(1) 01/12/06 5 OP36 12(5) 01/11/06 St Mary`s House DS0000017391.V308581.R01.S.doc Version 5.2 Page 24 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 The registered person should try to ensure that the wishes of the resident and relatives are documented with regard to the use of bed rail equipment. Signatures should be obtained to indicate their agreement. Where residents do not have allergies the registered person should consider recording this on the medication administration records. The registered person should consider holding regular staff meetings and fully record these. 2 3 OP9 OP36 St Mary`s House DS0000017391.V308581.R01.S.doc Version 5.2 Page 25 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 House DS0000017391.V308581.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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