Inspection on 18/05/05 for St Mary`s Mount

This inspection was carried out on 18th May 2005.

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 14/06/06

St Mary`s Mount 07/12/05

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 Marys Mount Holly Road Uttoxeter Staffordshire ST14 7DX Lead Inspector Sue Jordan Unannounced 18 May 2005 09:50 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 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 Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Marys Mount Address Holly Road Uttoxeter Staffordshire ST14 7DX 01889 562020 01889 562020 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) HAS Careplus Limited Mrs Elizabeth Smith Care Home 30 Category(ies) of 14 DE(E) registration, with number 30 OP of places 7 PD(E) St Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18 January 2005 Brief Description of the Service: St. Mary’s Mount stands in its own grounds where the local Social Service Day Centre is also to be found. It is located 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. Access to the upper residential floor is either by stairs, or by a shaft lift. There were 25 residents in the home at the time of the inspection.The dependency level of residents is varied and fluctuating.There are two adjoining lounges and a separate dining room that can also be used as a quiet area. There is a small sitting area in the inner hallway.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. A separate smoking area for residents has been created since the last inspection. St Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five and a half hours and the methodologies were pre-inspection analysis, discussions with staff, service users, the manager and a relative, a tour of the environment and scrutiny of three resident’s care records and three new care staff files. What the service does well: Assessments are carried out on potential residents and families are informed of the Home’s services prior to admission. The Home responds well to health concerns, calling on the expertise of relevant medical professionals as required. Families are made very welcome in the Home. The quality of the food is excellent, made with fresh ingredients and of nice sized portions. Complaints are taken seriously and prompt appropriate action taken to address them. Regular training is organised for the staff team. The management of service users’ monies is safe and all transactions are well accounted for. The Home is run by an enthusiastic manager, who is well supported by the proprietors and a committed staff team. St Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Care planning still needs improvement to ensure that all the required information is available to staff as to how they are to meet the residents’ needs. It would also be good to see more resident or family involvement in the care plans. Care plans should be reviewed monthly. There are a number of environmental improvements needed, some of which have been discussed with the proprietors and reasonable timescales allowed. Others were identified at this inspection and include providing an appropriate sluice facility and making sure that the bathroom facilities are useable and furnished with materials, which can be kept hygienically clean. The Home has been given until December 2005 to provide bedroom door locks, which comply with fire safety standards. The bedrooms themselves however are quite sparsely furnished and it is recommended that an audit be carried out to see what is available and of good standard and what is required. The manager had started a staff supervision programme, however this has lapsed a little and she is required to re-implement it. Recruitment procedures must be more thorough to ensure that the Home receives two references for all new staff and that they gather the required information for that person’s file. St Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 Page 7 More emphasis must be placed on the Health and Safety in the Home, including ensuring that pipes and radiators in the residents’ areas are covered. 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 Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection St Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 Page 9 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 standard(s) 1, 3, 4, 6 Assessment of prospective residents takes place prior to admission to ensure that the Home can meet their needs. Families are given the information needed to enable them to make an informed choice. EVIDENCE: The manager reported that the Statement of Purpose has been amended again since the last inspection although a copy of this was not seen at this inspection. A new and separate smoking area has been created since the last inspection and it was advised that this facility be included in the Home’s documentation. There have been no new residents admitted to the Home since the last inspection. However a discussion with a relative confirmed that the manager carried out a pre-admission assessment in the hospital. She also stated that she received the Home’s ‘pack before her Mother moved into St Mary’s Mount. This Home was chosen for its locality. It was reported that the Home communicates well with the family and keeps them informed of any concerns St Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 Page 10 or issues. The daughter is satisfied that this Home can meet her Mother’s needs. There is evidence available that the manager refers any concerns or contentious issues to the relevant professional experts. This has resulted in multi-disciplinary meetings being held and joint decisions being made. There is regular district nurse input in the Home as well as a visiting chiropodist. An optician has recently visited and tested a number of the residents’ eyesight. The Home does not offer intermediate care. St Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 Page 11 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 standard(s) 7, 8 Although there have been some improvements in care planning more work must be undertaken to ensure that the staff have all of the information required as to how they are to meet the residents’ needs safely. EVIDENCE: Three care plans were checked at this inspection. Although some progress has been made to improve and expand the information, there is still more work required. It was identified at this inspection that some specific needs have not been included in the care plans, for example in one case dietary and health needs and in another, information as to how the diet of a ‘diet-controlled diabetic is to be managed. There is also a lack of risk assessments and the manager must ensure that she check whether there are any risks to the residents or staff for each given task and if necessary carry out an assessment. The manual handling assessment tool used at the moment only states whether or not equipment is to be used and how many care workers are required. In the event of manual handling being required, more information must be available to staff as to how this is to be done. Staff must then follow these instructions in order that they do not St Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 Page 12 place themselves, their colleagues or the residents at risk. It is recommended that staff sign their agreement and compliance to these assessments. The Home use a daily-notes system, however this is not completed daily in all cases. This was discussed at the inspection and whilst it is accepted that it may not be necessary to complete these notes every day for every resident, the manager must still ensure that she is able to monitor whether the residents are receiving the care they require, including bathing and personal care and weight monitoring. The care records should be reviewed on a monthly basis. It was identified in one case that one resident’s care plan needs more information as to how his health needs are to be met. However generally there is evidence of health monitoring and appropriate referrals to the relevant professionals. Records are kept of medical visits and appointments. An optician has recently attended some of the residents. Due to specialised equipment they were also able to test the residents with dementia care needs and this has resulted in the provision of glasses. St Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 Enthusiastic efforts are made to provide activities and stimulation for the residents, which could be improved by allowing the responsible person more structured time. Visitors are welcomed in the Home and the quality of the food provided is excellent, however it would be good to see the residents being offered more choice. EVIDENCE: One of the senior care workers is responsible for organising activities and leisure events in the Home. On the day of this visit, music and movement took place in the afternoon. A relative also spoke of monthly bingo sessions. Funds have been raised to provide a croquet set and a rose garden has been attractively planted. A garden fete and barbeque is being planned. Activities usually take place on an ad-hock basis and depend on whether there are enough staff for the senior care worker responsible to be released. It is recommended that the Home employ a specific person to arrange and provide structured and more regular activities. A previous recommendation was made that the existing senior organising the activities receive some training to assist her in her enthusiasm. The manager reported that she still intends to address this. St Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 Page 14 The relative spoken to during this visit said that she has always felt welcome in the Home and a number of visitors were seen coming and going. During discussions with a relative and her daughter, the resident said that she thought they were able to have a bath whenever they request and the manager confirmed that this is available. At this time the Home also provides meals to the adjacent Local Authority day centre and discussions are due as to how this can be better organised. The cook and the Home’s manager are concerned that the residents of the Home take ‘second place’ and that any choices available are not to them. Whilst the quality of the food provided in the Home is excellent, it would be good to see more daily choices being offered. The present cook cannot logistically provide more choice for the day centre clients and the residents of the Home, within her working hours and without more cooking assistance. The Home has recently recruited a new cook, who is experienced and well qualified. Lunch was shared with the residents and comments such as, “I really enjoyed that dinner” and “ This is lovely” were heard. A new cooker has been purchased and a new fridge has been ordered. The kitchen has been reorganised and more fresh and homemade ingredients are being used. Four weekly menus are presently in place and a weekend menu has been devised for the chef working during that period. The dining room is potentially a pleasant setting, although it would benefit from being re-decorated and the current light bulbs without shades do not enhance a ‘homely’ feel. The tablecloths are very worn and replacement should be considered. The manager reported that decoration and refurbishment of the dining room is planned following the completion of the work needed in the lounges. St Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 Complaints are taken seriously in the Home and the appropriate action taken to protect the residents. EVIDENCE: Discussions with a relative confirmed that she knew who to complain to, if she had any concerns. She thought that the complaints procedure is included in the information given to the family prior to their Mother’s admission. A complaint was received by the CSCI in February 2005. There were concerns regarding the visibility and availability of staff in the Home, some infection control and hygiene issues and some staff demoralisation. A visit was made to the Home and the complaint discussed with the manager. As a result, an action plan was drawn up. Additional staff recruitment has taken place, staff are now taking staggered breaks-the senior on duty being responsible for ensuring a member of staff is always ‘on the floor’ and a staff meeting was held to discuss the issue of incontinence aid disposal. The complainant was satisfied with these responses and the continuation of this action confirmed during this visit. There is a copy of the multi-disciplinary Adult Protection procedures in the Home and staff are receiving training in Adult Abuse. New staff now receive this training as part of their induction. Discussions with the manager indicated a lack of awareness of the Local Authority Adult Protection Team, their role and the referral process in the event of an abusive situation occurring. It is therefore recommended that the manager contact this team and seek further advice and training for the manager and staff team. It would be useful for St Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 Page 16 them to have an understanding of the local procedures to follow in order that their actions do not compromise a possible investigation. The Home is now making all the required checks for staff prior to employment, however some of the recruitment processes should be tightened. St Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 24, 25, 26 There is evidence that the proprietors are gradually improving the environment, which when complete will greatly improve the homeliness and comfort of the Home. EVIDENCE: A tour of the Home was made during this visit. There is evidence that decoration of the Home is taking place on a rolling programme. Bedrooms are now being decorated as soon as they become vacant. There are plans to decorate the two lounges very soon, followed by the dining room. This will greatly enhance the environment in the Home. New carpets and curtains are being planned. A separate smoking area has been provided, which means that the communal lounge is smoke free. Six new chairs have been purchased for one of the lounges. St Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 Page 18 As yet, locks have not been fitted to the bedroom doors. Quotes are presently being obtained. The Commission for Social Care Inspection has given a dead line of 01/12/05. Locks are gradually being fitted to some bedroom furniture for secure storage. The bedrooms are still rather sparsely furnished and an audit of the furniture in place and that needed is recommended. The majority of the radiators in the Home have been covered, however whilst walking around the Home a couple were found to be uncovered and rather hot. This included the upstairs bathroom and the new smoking area. A large central heating pipe on the first floor was also very hot to the touch and a pipe in room 5 needs boxing in. Another area, which should be re-assessed is the infection control procedures in the Home. There is one laundry area, in which the sluice is also situated. There are no separate hand washing facilities for the staff working in the laundry. The laundry assistant demonstrates commitment to her role, however she is having to start the day cleaning commode pots and these are kept on the window sill of the laundry. The clinical waste bin is also kept in the laundry. The laundry assistant is allergic to latex and therefore is wearing ‘kitchen-style’, washing up gloves. Although she gets a fresh pair every day, there are possible infection control issues. The use of alginate bags for soiled linen can improve infection control procedures. In order that the best advice be obtained, it is recommended that the infection control nurse be contacted. There are two bathrooms on the first floor, only one of which is in use. In order to maintain the appropriate ratios this bathroom should be made usable. The flooring in both bathrooms is unhygienic and cannot be cleaned properly and this flooring is also around the bath, which should be replaced. There are toilets on the ground floor, which do not have wash hand basins and a previous requirement was made that these be fitted. This has not, as yet been completed. It was discussed at this inspection whether a new sluice facility could be sited in one of these areas, but the appropriateness of this will need to be discussed with the infection control nurse. St Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 Staffing levels in the Home have improved and there are plans to improve this further. However the management must ensure that the recruitment procedures are carried out thoroughly, in order that the residents are fully protected. EVIDENCE: A previous concern was raised regarding staffing levels. The manager had been working permanently as a member of the care staff team and unable to complete all of her managerial tasks. This is being addressed with the recruitment of new three new care staff and more applications are to be processed and interviews held. It is the Home’s intention to have a minimum of three care staff plus the manager working throughout the day. Due to the three new care staff, the future rota shows that this is possible and that at times there are going to be four care staff and the manager. This will enable the manager the time to complete her tasks and undertake the work needed to meet any outstanding requirements. Three care staff files were checked at this inspection. The appropriate checks have been made, however the manager was asked to be more thorough in her recruitment procedures. For example, one of the application forms was incomplete and a reference did not have an address on and also could not be cross- referenced to the application form. There have been difficulties in obtaining a reference from an ex-employer and the manager was advised to evidence within the file that attempts have been made and obtain a character St Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 Page 20 reference from an alternative nominated referee. All of the files require proof of identity and a photograph. A discussion was held with the new cook and her account of the Home’s recruitment process was satisfactory. Criminal Records Bureau disclosures are still needed for a very small number of existing employees. In order to safeguard the residents two references and appropriate checks should be made prior to employment. In the first instance telephone references can be obtained, however records should be made of the conversation and these should be backed up in written form, as soon as possible. Induction booklets were ready for the new staff and training has been booked in first aid and fire safety. Manual handling training has been delivered and food and hygiene training has been booked. The training matrix was not seen at this inspection. It has been recommended that the manager contact the Local Authority Adult Protection team to access training on local vulnerable adults procedures and that the manager receive training in Health and Safety and risk assessment. St Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 35, 36, 37, 38 The Home is run by an enthusiastic manager, who is well supported by the proprietors and a committed staff team. In order that the residents and staff are fully protected Health and Safety assessment should be given higher priority and a more regular supervision programme implemented. EVIDENCE: The manager is enthusiastic and committed to raising the standards within the Home and it is hoped that given more staff and time she will be able to further develop the work done so far. The recruitment of an administration officer has proved to be a bonus to the Home and she is now working five days a week. She is able to help the manager with some of the administrative duties, including recruitment, minute taking and management of the petty cash and service users’ funds. The Home also has a senior care team, who are able to lead and manage the shift in the absence of the manager. St Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 Page 22 The Home does not receive benefits on behalf of the residents as this is dealt with by the families. The families bring money into the Home for the residents and this is booked in and signed for. All transactions are signed and receipts obtained and kept. A discussion was held regarding one of the residents, who does not receive money from family for his toiletries etc. The Home is presently supplying and purchasing these and other necessities. It was advised that the Home contact the social worker for advice. The Home will need to check their individual contracts and the Service Users’ Guide, which should clearly state what is included in the fees and what the residents have to buy themselves. The manager had previously started a supervision programme for staff but admitted that this is not up to date. She was advised to arrange staggered supervisions rather than attempt to do them all at the same time. Supervision of staff can take various forms, including one to one written sessions, observation of tasks, team meetings and appraisals. There should be evidence available that staff are formally supervised at least six times a year therefore records should be made. The senior care team could be involved in some staff supervision, for instance observations or running team meetings, which would assist the manager. The standard of the record keeping and the information within has improved although more work is required. The Health and Safety records were not checked at this inspection, however practically there are issues that have not been addressed by the management. This includes radiators and pipes, which require covering, infection control issues in the laundry area and the storage of incontinence pads in the smoking area. These were however removed on the day of the inspection. A risk assessment is required for the smoking room, which will also mean changes to the fire procedures in the Home. The two residents using this room have the understanding needed to understand the fire procedures, if explained to them. The manager agreed to contact the Fire Safety Officer and have an informal discussion about the smoking room, the proximity of the fire extinguishers and other requirements, which might be necessary. The smoke detector has been removed and a heat detector put in it’s place and there is an extractor fan. A general discussion took place around Health and Safety. It is recommended that a regular audit of the Home take place, which ensures that any risks are identified and removed. The persons responsible should ideally be trained in Health and Safety and risk assessment. St Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 2 x x 2 2 2 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x x 3 2 3 2 St Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 Page 24 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15 Requirement Care plans must contain all of the information listed in NMS 3.3. More detail is needed in the care plans in order that staff have the information required to meet the assessed needs of the residents. Care plans must be reviewed monthly. Previous Requirement Wash hand basins must be provided in all accessible toilet areas. Previous Requirement Bathrooms should be made usable and ensure that the baths and floors are covered in a way which maintains a satisfactory standard of hygiene. Locking devices should be provided as standard on bedroom doors to promote privacy and dignity for the service users. Use of approved locking device to be as recommended by the Fire Officer. A lockable storage space must be provided for valuables in service users’ rooms. An agreed rolling programme to be implemented within the following timescale. Timescale for action 01/08/05 & on-going 2. 21 23 01/12/05 3. 21 13 (3,4a), 16 (j),16 (2j) 12(4)(a) 01/12/05 4. 24 01/12/05 St Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 Page 25 Previous Requirement. 5. 6. 7. 8. 25 26 26 29 23 (2p), 13 (4a,c) 23 (2k), 13 (3) 16 (2j), 13 (3) 19 (1 a,b,c)Sch edule 2 Folowing risk assessment, radiators and pipework should be covered in the Home. Sluice facilities must be provided. Hand washing facilities must be available in the laundry area. Information and documents in respect of staff working in the care home be maintained as specified in Schedule 2 and that all staff should have CRB check. Previous Requirement. Evidence is required that staff receive structured supervision at least six times a year. Advice must be sought from the Fire Safety Officer with regard to the smoking room. The Health and Safety in the Home must be given higher priority, including regular assessment of risk and the subsequent appropriate action taken. 01/08/05 01/12/05 01/12/05 01/07/05 & on-going 9. 10. 11. 36 38 38 18 (2) 23 (4) 13 (4 a,b,c) 01/07/05 & on-going 01/07/05 01/07/05 & on-going 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. 3. Refer to Standard 1 1 12 Good Practice Recommendations It is recommended that the separate smoking room facility be included in The Statement of Purpose It is recommended that the management check that The Service Users Guide contains clear information as to what is covered in the fees. It is recommended that the senior staff member responsible for organising activities access training to further develop her skills in this area and that she be given specific allocated time for structured and more regular activities. It is recommended that the Home explore how thay can E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 Page 26 4. 14 St Marys Mount 5. 6. 15 24 offer more choices to the residents and this includes meals. It is recommended that table cloths be replaced and lamp shades be provided to enhance the dining room. It is recommended that an audit of the bedroom furniture be carried out to see what is available and what is still needed to meet National Minimum Standard 24. St Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Stafford - 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 Marys Mount E51-E09 S5003 St Marys Mount V228403 180505 stage 4.doc Version 1.30 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!