Inspection on 14/06/06 for St Mary`s Mount

This inspection was carried out on 14th June 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 Mount 09/04/08

St Mary`s Mount 18/10/07

St Mary`s Mount 29/06/07

St Mary`s Mount 07/12/05

St Mary`s Mount 18/05/05

St Mary`s Mount 18/01/05

St Mary`s Mount 29/11/04

St Mary`s Mount 26/01/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE St Mary`s Mount Holly Road Uttoxeter Staffordshire ST14 7DX Lead Inspector Sue Jordan Key Unannounced Inspection 14 June 2006 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 Mount DS0000005003.V297701.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 Mount DS0000005003.V297701.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary`s Mount Address Holly Road Uttoxeter Staffordshire ST14 7DX 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) 01889 562020 01889 562020 HAS Careplus Limited Mrs Elizabeth Smith Care Home 30 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (30), of places Physical disability over 65 years of age (7) St Mary`s Mount DS0000005003.V297701.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2005 Brief Description of the Service: St. Marys Mount stands in its own grounds within half a mile of the centre of Uttoxeter where a wide range of local shops and services can be accessed. There is a town bus route passing the gateway, and the railway station is about a mile away on the other side of the town centre. There were 24 residents in the home at the time of the inspection. The dependency level of residents is varied and fluctuating. The Home is registered with the Commission for Social Care Inspection to care for a maximum of 30 older people, 14 of who may have dementia care needs and seven a physical disability. There are 28 bedrooms, 26 of which are for single occupation, and two of which are shared. There are no rooms with en-suite facilities at the current time. There is separate smoking area for residents. The pre-inspection questionnaire completed by the manager and sent to the Commission for Social Care Inspection states that the present scale of fees is £304-£345 per week. The Home is managed by Mrs Elizabeth Smith. St Mary`s Mount DS0000005003.V297701.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over six and a half hours. This was a ‘key inspection’ and therefore all of the core standards were assessed. The methodologies used were scrutiny of the pre-inspection questionnaire completed by the manager and twenty-six Commission for Social Care Inspection comment cards. Discussions were held with a number of the residents, the manager, the administrator, a visiting relative, and some staff. Case tracking of three residents was undertaken, which included discussions and checking of their records. Observations were made of staff and service user interaction and non-personal care tasks. The records for two members of staff were checked. A random selection of the Health and Safety records were seen and a tour of the environment was taken. What the service does well: The management and staff make the residents’ relatives welcome and there are frequent visitors to the Home. The manager ensures that she receives assessment information from the Local Authority, prior to a resident’s admission in order that she can determine whether the Home can meet their needs. The health of the residents is closely monitored and appropriate medical intervention obtained. There is a consistent staff team and positive comments have been received regarding their dedication and caring attitudes. 64 of the staff team have achieved NVQ 2 or above. The food provided is of a high standard and the Home prides itself on their use of fresh produce. The proprietors and the manager have a history of co-operation and compliance with the Commission for Social Care Inspection. St Mary`s Mount DS0000005003.V297701.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Mary`s Mount DS0000005003.V297701.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 Mount DS0000005003.V297701.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): 1, 2, 3, 6 Quality in this outcome area is “good”. Assessments are received for prospective residents, in order that the manager can determine whether the Home can meet his or her needs. Residents and/or their relatives need to know how they can access the information contained in the Service Users Guide. EVIDENCE: An updated Statement of Purpose is available in the Home. The Home has developed a contract for privately funded residents since the last inspection. Of the eight Commission for Social Care Inspection comments cards completed by relatives, three stated that they did not have knowledge of the complaints procedure and two said that they did not have access to the latest Commission for Social Care Inspection report. Both of these elements should be contained St Mary`s Mount DS0000005003.V297701.R01.S.doc Version 5.2 Page 9 in the Service Users Guide and therefore the manager needs to ensure that this is freely available to residents and/or their families. It would not be possible to provide all of the residents with this document given their dementia care needs. However, the manager needs to ensure that all residents and/or their families are aware of its availability in the office. It was suggested that the manager write to the families and put a notice in the hallway. There have been three admissions to the Home since the last inspection. Their care records were checked and care management assessments and care plans were received for all three prior to admission. The senior team have also undertaken ‘in-house’ own assessments, although the manager was reminded that these documents should be dated. Care plans had not yet been developed for two of the new admissions, despite the fact that one has been in the Home for over a month. A requirement is made under National Minimum Standard 7. St Mary’s Mount does not provide intermediate care. St Mary`s Mount DS0000005003.V297701.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, 11 Quality in this outcome area is “adequate”. Although care planning has generally improved, they must be developed for new residents, ensuring that they and staff are not left vulnerable. EVIDENCE: Generally, care planning continues to improve and they have been reorganised. Individual risk assessments have now been completed and there is evidence that they are regularly reviewed. The manager was recommended that some of the information in the care plans should be expanded to provide staff with more specific guidance, as is what is required to meet service user need. For example, how staff should assist with personal care, if so identified. Care plans had not yet been developed for two of the new admissions, despite the fact that one has been in the Home for over a month. This leaves staff and the relevant service users vulnerable, particularly as complex needs have been identified, including diabetes and some behavioural difficulties. St Mary`s Mount DS0000005003.V297701.R01.S.doc Version 5.2 Page 11 The care records do contain evidence that the appropriate medical assistance is called when needed. A few of the residents receive attendance from the local District Nurse team and the manager is able to request their advice on a number of issues. The manager has undertaken assessments of wheelchair use and in particular the use of footplates. The decision not to use them should be based on a professional assessment by for example, an occupational therapist. The manager is to contact the Health Protection Nurse for advice on another issue. The medication procedures were not observed during this inspection, however staff confirmed that they had received medication training. On checking the training records, it was ascertained that this was two years ago and therefore a recommendation was made that the competency of staff administering medication be assessed at least annually. The registered person has developed a protocol, as previously required by the Commission for Social Care Inspection to ensure that residents’ privacy is maintained in a shared toilet and shower area. New bedroom cabinets have been purchased for some of the bedrooms and the administration officer conducting the tour was advised of the need for lockable storage. Privacy and dignity issues were identified at the last inspection, particularly during the lunch time period. These have mostly been addressed, however a shortage of staff does not assist them in this matter. For example, five residents require assistance with feeding, many need verbal prompting and their meat cut up and medication administration is required at mealtimes. Three care staff are available for these tasks. This is further explored throughout this report. Observations of the staff during this inspection were of positive and respectful attitudes to the residents and comments made were, “very friendly and caring staff” and, “nothing is too much trouble”. The manager is presently consulting with families regarding the care of their relatives at the difficult and sad time of their death. St Mary`s Mount DS0000005003.V297701.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 “adequate”. The present staffing levels do not allow them to provide suitable stimulus and choices for the residents. EVIDENCE: The manager organises outside entertainers to come into the Home as often as possible and on the day of the inspection ‘movement and music’ was organised for the afternoon. However there is a lack of daily stimulus for the residents. The care staff are over stretched and report being unable to spend quality time with the residents or organise group activities for them. This was observed during the visit. There were three care staff on duty caring for twenty-four residents many of whom have complex needs. Staff time has to be concentrated on basic care duties. A recent resident in the Home has had some difficulties settling. However a staff member reported a very positive response after having a rare opportunity to spend just twenty minutes one-to-one with the relevant person. Unfortunately the staff do not normally have the time. St Mary`s Mount DS0000005003.V297701.R01.S.doc Version 5.2 Page 13 The staffing levels are also a concern for relatives. This was confirmed in comments cards received by the Commission for Social Care Inspection and in a discussion during the inspection. Comments cards received from the residents also confirm their concern regarding staffing levels and the lack of activities. The manager is currently monitoring the daily routines in the Home. She has spoken to the senior staff about acceptable bedtime and rising times and encouraging resident choice rather than institutionalised staff practices. She is also planning spot checks of the various shifts. One of the residents said that he was enjoying the ‘world cup’ and that he and another resident had a beer whilst they watched the matches. Visitors are encouraged in the Home and this was confirmed in the eight questionnaires received by the Commission for Social Care Inspection. The registered persons have been asked previously to examine the issue of choice for the residents. During this visit, residents were offered an alternative to the menu if they declined their meal and a choice of a hot and cold meal is available for lunch. A cooked breakfast has been introduced on a Sunday for those that request it. The meals themselves are of a high quality and the cook prides herself on the use of fresh ingredients, supplied locally. Pureed foods are piped individually retaining individual colours and tastes. Two residents are presently having their meals in their bedrooms and in total seven require assistance to eat their meals. A number of residents require verbal prompting and assistance to cut up some foods. Three care staff were available to complete this tasks and they are over stretched to do so whilst ensuring that the food stays warm. The possibility of obtaining a heated trolley was discussed, which it was thought would benefit the residents greatly. It would allow the cook to offer a greater choice of hot food and the residents to make a visual choice. It would also mean that the care staff could concentrate on assisting the residents rather than be running backwards and forwards from the kitchen. Food could be cut up if required, in a more dignified way, which does not advertise the residents’ difficulties. The manager agreed to look at the mealtime routines and implement a more relaxed structure. The present system of working is stressful for both the residents and the staff. The Environmental Health Officer visited the Home in January 2006 and their recommendations have been actioned. The cook was given a useful pack to assist her in her monitoring of the food standards in the home. St Mary`s Mount DS0000005003.V297701.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 “adequate”. Residents and relatives need to be made more aware of the complaints procedure. EVIDENCE: Some relatives report that they are not aware of the complaints procedures and the manager agreed to communicate this knowledge. The manager reports within the pre-inspection questionnaire that there have been no complaints made within the last twelve months. However during discussions it was ascertained that some relatives had expressed verbal concerns, which had not been logged. The manager was advised to log all concerns and minor complaints and the action taken to address them. This will provide written evidence, if necessary that complaints will be listened to, taken seriously and acted upon. The staff have completed training in the Protection of Vulnerable Adults and appropriate recruitment checks are made. Risk assessments have now been carried out for the residents and for the environment. The manager must ensure that all of the systems in the Home completely protect the residents and these are identified throughout this report. These include care plans for new residents and appropriate and safe staffing levels. St Mary`s Mount DS0000005003.V297701.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24, 25, 26 Quality in this outcome area is “adequate”. The proprietors continue to make environmental improvements to the Home, raising the standard of accommodation for the residents. EVIDENCE: The proprietors continue to make improvements to the environment. A number of bedrooms have been re-decorated, re-carpeted and new furniture provided. A separate sluice room has been created and a hand-washing sink fitted in the laundry. Work is being undertaken on the ‘rose garden’, which will create a pleasant space for residents to sit in the summer. The water temperatures are being tested monthly by the manager and a protocol in place for staff to test the water prior to bathing a resident. Radiators and exposed water pipes have been covered. St Mary`s Mount DS0000005003.V297701.R01.S.doc Version 5.2 Page 16 The manager and proprietor are undertaking six-weekly Health and Safety audits of the Home and environmental risk assessments have been undertaken. The manager was asked to risk assess any sloping areas of the Home. It was also noticed that some of the floors levels are uneven and this needs to be rectified. Bedding and crockery are gradually being replaced. New dining room chairs have been ordered. A magnetic catch has been ordered for the residents’ smoking room. At present there are twenty-four people resident in the Home, however there have recently been twenty-six. The registered persons are reminded that the appropriate bathroom ratios are one to eight residents and therefore the upstairs bathroom needs to be usable. The manager reports that there is an assisted available bath chair that just needs fitting. She was reminded that this should be included in any maintenance checks and servicing. The Home has had a visit from the Environmental Health Department in January 2006 and the requirements implemented. On the day of this inspection there were three domestic staff cleaning the Home and it was seen to be clean and hygienic. However a lack of cleaning staff at the weekend could compromise this situation as care staff are having to clean the Home and care for the residents. St Mary`s Mount DS0000005003.V297701.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is “poor”. The staff are well regarded by the residents and the relatives and have achieved excellent overall NVQ results, however the present levels need to be reviewed to ensure that there are sufficient number to meet the dependency levels of the residents. EVIDENCE: Some of the comments received from relatives about the staff at St Mary’s Mount include: “I always find St Mary’s Mount very pleasant, the staff really do care”. “The staff and the care in St Mary’s Mount is above excellent, myself and my relative have found the home well above our expectations”. A resident said, “The girls are lovely, nothing is too much trouble”. The present ratio of staff is: AM: 3 to 4 CW, (3 at weekends) PM: 3 CW Night: 2 CW There are presently twenty-four people resident at the Home. St Mary`s Mount DS0000005003.V297701.R01.S.doc Version 5.2 Page 18 Monday to Friday there are three cleaning staff, one cook, one laundry assistant and one kitchen assistant. At the weekends there is one cook only. The manager is included in these care worker ratios and as such she will have responsibilities, which will take her away from the residents. Three of the relatives reported their concerns regarding staffing levels within the Commission for Social Care Inspection comments cards and a relative spoken to on the day of the visit said, “The Home is first class, the staff are lovely and the manager is smashing, but I don’t always think there are enough staff on”. Concerns identified during this inspection with regard to the amount of care staff to care for the residents are reflected throughout this report. A large amount of the residents are highly dependent and require complete support. The manager reported that she is presently requesting re-assessment for a number of residents in an attempt to secure additional funding. In the meantime the registered persons are reminded that they have a responsibility to ‘ensure that all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users’. (Care Homes Regulations 2001, 18 1a). The present level of staff is having a negative impact on the care in the Home; mealtimes are chaotic, staff cannot spend quality time with the residents and bathing can only be done on a weekly basis rather than on a needs or requests basis. There also has to be concern about the appropriate supervision of the residents, for example if two care workers are bathing one person, only one care worker is available to supervise twenty-three remaining residents in a very large building. The registered persons must undertake a review of staffing levels based on the needs of the residents and ensure that suitable numbers are available at all times. This should include an assessment of the individual residents needs and the risks involved. Observations of the staff during this inspection were of positive and respectful attitudes to the residents, however they are overstretched. None of the cleaning staff work at the weekends and there is no laundry or kitchen assistant. This means that the staff are also having to clean the home, make the drinks and do the laundry as well as care for the residents. It is recommended that staff resources be used more efficiently. The staff are to be commended for their hard work in achieving NVQ awards. Of the sixteen care staff employed, eleven have NVQ 2 or above, which is a percentage of 64 . The manager is due to commence the NVQ Assessors award. St Mary`s Mount DS0000005003.V297701.R01.S.doc Version 5.2 Page 19 Recruitment procedures have improved and scrutiny of two new staff members’ records evidenced that all appropriate checks are being made and documentation held. Staff have just received first aid and fire training. The Home has a training plan in place, but is encouraged to maintain the impetus; food and hygiene and manual handling training are overdue. The manager is making efforts to plan these courses. Staff are to complete additional training in dementia awareness and infection control. Staff confirmed that they had received medication training. On checking the training records, it was ascertained that this was two years ago and therefore a recommendation was made that the competency of staff administering medication be assessed at least annually. St Mary`s Mount DS0000005003.V297701.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 this service. The manager has implemented staff supervision and monitoring systems in the Home, which will enable her to ensure the residents are receiving the service they need. EVIDENCE: The manager, Elizabeth Smith is appropriately qualified and keen to update her knowledge. She is presently undertaking the NVQ Assessors award and an NVQ in Health and Safety in the workplace. The manager is starting to develop a staff supervision system and all senior staff have attended a performance development review. The manager will continue to supervise the senior staff. Each senior is to have a group of staff to supervise and the plan is for these sessions to be bi-monthly. The manager is St Mary`s Mount DS0000005003.V297701.R01.S.doc Version 5.2 Page 21 recommended to undertake at least one supervision session per member of staff annually herself, which will give her the opportunity to monitor progress and the staff formal opportunity to be supervised by the manager. The manager was reminded that she should also request her own written, formal supervision from the proprietors. Although she is informally supervised on a regular basis, there is no written record. Staff supervision will continue to be assessed at future Commission for Social Care Inspections. Staff meetings have been held for the seniors and the care workers. Future meetings are planned. Staff hand over relevant information at the beginning of every shift. The manager is monitoring the care practices in the Home and is undertaking spot checks of the various shifts. Quality Assurance questionnaires have been received from the relatives. The analysis was not available during this inspection. The Home does not manage the residents’ finances. This is the responsibility of the families. The proprietor and manager undertake a full audit of the Home on a six weekly basis, which includes Health and Safety and care practices. This is excellent Quality Assurance evidence and to be encouraged. The pre-inspection questionnaire completed prior to this visit by the manager indicated that the Home and Health and Safety equipment are maintained appropriately and the manager has undertaken Health and Safety risk assessments. She was however asked to risk assessment any sloping areas and check the floor levels. A recent resident’s accident was not recorded on the appropriate form. The manager was reminded that she must notify the Commission for Social Care Inspection of all such accidents. St Mary`s Mount DS0000005003.V297701.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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X 3 3 3 STAFFING Standard No Score 27 1 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 St Mary`s Mount DS0000005003.V297701.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 OP1 Regulation 5 (2) 22 (5) Requirement The registered person must supply a copy of the Home’s Service Users Guide to each service user and/or their relative. This will ensure that all have access to the Home’s complaints procedure and most recent inspection Commission for Social Care Inspection report. Care plans must be developed for all residents as soon as possible following admission. The manager must seek professional guidance from appropriate medical departments. In this case a professional assessment regarding the use of foot plates on wheelchairs and advice for staff on the containment of infection diseases. The registered person, following consultation with the residents, is required to examine further ways of providing recreation, fitness and training, which meet their diverse needs. The manager must explore how The Home can offer more DS0000005003.V297701.R01.S.doc Timescale for action 01/07/06 2 3 OP7 OP8 15 13 1 (b), 13 3 01/07/06 01/07/06 4 OP12 16 2 (m, n) 01/08/06 5 OP14 12 (2, 3, 4b,) 01/07/06 St Mary`s Mount Version 5.2 Page 24 6 7 8 OP19 OP21 OP27 23 (2a, b), 13 (4) 23 (2j) 18 (1a) 9 OP30 18 (1ci) 10 OP38 Schedule 4 (12a) individual choices to the residents. Previous Requirement The registered persons must assess the hazard of uneven floor levels to the residents. The Home must maintain the appropriate ratio of usable bathrooms. The registered persons must undertake a review of staffing levels based on the needs of the residents and ensure that suitable numbers are available at all times. Food and hygiene training must be provided at the appropriate frequencies. Previous Requirement Accidents must be recorded appropriately. 01/07/06 01/08/06 01/07/06 01/08/06 15/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations It is recommended that the manager inform relatives in writing of the availability of the Service Users Guide to ensure that they have access to the Homes complaints procedure and the latest Commission for Social Care Inspection report. It is recommended that some of the information in the care plans be expanded to provide staff with more specific guidance as is what is required to meet service user need. It is recommended that the competency of staff administering medication be assessed at least annually. It is recommended that the staff undertake the ‘Safe Handling of Medicines’ training. The registered person is recommended to consider the purchase of a heated trolley for meal times. It is recommended that the manager log all concerns and DS0000005003.V297701.R01.S.doc Version 5.2 Page 25 2 3 4 5 6 OP7 OP9 OP9 OP15 OP16 St Mary`s Mount 7 8 9 OP36 OP36 OP27 complaints and the action taken to address them. The manager should also receive formal, recorded supervision and an annual performance development review. The manager is recommended to complete a supervision with each member of staff herself annually. It is strongly recommended that staff resources be used more efficiently to ensure that appropriate auxiliary staff are available at weekends. St Mary`s Mount DS0000005003.V297701.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Mount DS0000005003.V297701.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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