Inspection on 09/04/08 for St Mary`s Mount

This inspection was carried out on 9th April 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Mary`s 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 18/05/05

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 Jane Capron Unannounced Inspection 13:00p 9th and 16th April 2008 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.V361878.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.V361878.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 stmarysmountenquiry@tiscali.co.uk 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.V361878.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th December 2007 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. The service 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. The service is in the process of altering the accommodation to provide all single bedrooms and to provide a few rooms with ensuite facilities. There is separate smoking area for residents. The present scale of fees is £370-£465 but people may wish to obtain more up to date information from the service. Other additional costs would include hairdressing, private chiropody, personal toiletries and newspapers. St Mary`s Mount DS0000005003.V361878.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes We visited the service over a 2-day period and the service did not know we were visiting. During our visit we spoke to people living at the service, staff and the manager. We also spoke to a heath professional visiting the service and to people that were visiting a relative. Prior to this visit we sent surveys to people living at the service, relatives and professional staff to gain their views of the service. During this inspection we looked at the lifestyle that people experienced including how the service was meeting people’s health and personal care needs and whether they were provided with choices over their lives. We also looked at the knowledge and skills of the staff and whether the service’s way of employing staff was protecting people. Since the last key inspection one visit has been made to the service to check the service’s progress in meeting requirements. Due to the service’s failure to meet requirements we sent them a warning letter advising them that enforcement action may be taken. The service provided us with an action plan identifying how they were to meet the requirements we had made. What the service does well: People tell us that they like living at the service. They say ‘that the girls are good’ and ‘that they are caring’. Staff show people respect and encourage people to be as independent as possible and to make choices about their lives. People told us they liked the food. Comments included ‘food good’ and ‘there is always a choice’. The service completes an assessment showing people’s needs before anyone is offered a place. People can visit the service before deciding to live there. There is a complaints procedure that is on show in the service and is in the information given to people that live at the service. Since our last visit there have not been any complaints. The accommodation is overall of a good standard. There are large communal areas, being two large well decorated lounges and a nice dining room. Bedrooms are big enough for people and people can bring in their own belongings including small pieces of furniture. All bedrooms and bathrooms and toilets can be locked. St Mary`s Mount DS0000005003.V361878.R01.S.doc Version 5.2 Page 6 The service is kept clean and hygienic and staff know how to reduce the likelihood of infections spreading. There is a good system for checking the service that is provided to people. This includes doing checks on the building, checks that medication is given properly and getting the views of people that live there, their relatives and staff. What has improved since the last inspection? What they could do better: Although the service is providing some good outcomes for people that live there are still some areas that need to be addressed. Where there are concerns over the amount of fluid people are drinking accurate records should be kept. This will make sure that staff know if they are drinking enough. St Mary`s Mount DS0000005003.V361878.R01.S.doc Version 5.2 Page 7 If people have bedrails to protect them the service must have a system in place to make sure they continue to be safe. The service needs to make sure that it seeks 2 references when it is recruiting staff rather than accepting references brought by staff themselves. Although the service is training staff in how to safeguard people the service needs to make sure that staff know what to do if there is a concern that someone has been abused. As well as the above requirements we made a number of recommendations that would improve the service for the people that live there. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Mary`s Mount DS0000005003.V361878.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection St Mary`s Mount DS0000005003.V361878.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Information about the service is provided to people so that they know what their life will be like if they live there although this could be provided in different formats. Assessments of people’s needs are completed so that only people’s whose needs can be met are admitted. EVIDENCE: Copies of the Statement of Purpose and service user guide are available at the service. They have been updated since we visited last time and now provide the information needed to show people what the service offers. The service user guide is provided to all people living at the service and to people considering moving to the service. The service user guide includes information about how the service provides a service to people with dementia care needs. It also provides some information from people living at the service and from relatives. There is scope for further development in the information providing them in different formats for example through the use of pictures and larger print. St Mary`s Mount DS0000005003.V361878.R01.S.doc Version 5.2 Page 10 Our examination of care records confirm that prior to anyone moving to the service an assessment of their needs is completed. These assessments include people’s health and personal care needs as well as their social care needs including relationships, activities and spiritual needs. The assessments now include a social history and pen picture of the person. The service provides people with the opportunity to visit the service before deciding to live there. One person we spoke to said that they visited several times before moving in. Placements are also made on a trial basis and are only made permanent following a review that contains all significant people. The service does not provide intermediate care. St Mary`s Mount DS0000005003.V361878.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service is now developing individual person centred plans that identify the specific needs of each person but still needs to ensure that people are always involved in developing their care plans. Peoples’ health and personal care are generally being met. The service’s now has a robust medication system that is making sure that people receive the correct medication and any errors can easily be detected. EVIDENCE: A sample of files confirms that the service has made progress in developing care plans about the people living at the service. Plans contain information about people health and personal care needs. Plans now have more information about people’s social care needs including contain a brief pen picture of each person to give staff information about people’s live experiences and to show the activities and lifestyle they previously enjoyed. Where people have communication needs these are identified and plans show how staff should respond. One person does not like using her hearing aid and the service St Mary`s Mount DS0000005003.V361878.R01.S.doc Version 5.2 Page 12 has put in system in place to use notes to make sure she is given information. The plans contain information about any cognitive impairment and identify how this affects them. Plans are being reviewed but not all demonstrate the involvement of the person concerned or their relatives if appropriate. The service is starting to make small changes to the environment to aid people to orientate themselves to the building. Pictures that specifically relate to people are being put on bedroom doors for example a picture of when someone was married and a tractor for someone that was a farmer. Staff we spoke to are aware that issues of aggression and violence can be a way a person has of communicating unhappiness or distress. Plans show that where people show aggression triggers have been considered and plans in place to show staff how to respond. There is still some scope for staff to develop these skills and the service tells is that they are due to have training in this area of the work. A health care professional that works with people with mental health issues said that they are satisfied that the service is alert to changes in people’s health and refers concerns appropriately. They also say that the staff communicate issues to them and respond to any advice given. Plans are in place to meet people’s nutritional needs and one person is having their nutritional and fluid intake monitored. Whilst records are kept these do not accurately record the amount of fluid taken. People’s weight is monitored and people are referred to health professionals if concerns arise. The service monitors people’s pressure sore areas and has regular contact with the district nursing service and the doctor. Where necessary people have pressure-relieving equipment. One person is being cared for in bed and bedrails are being used. An assessment is present that identifies the need for rails and that regular checks are completed to make sure the rails are safe. Whilst the manager states that this is done we would recommend that the checks on the safety of the rails are properly recorded. Staff at the service tell us that the personal care people receive has improved. This issue had been raised with us in the staff survey we sent but a system of a morning daily checks is now in place that makes sure that people are always appropriately dressed and have their hair and oral care fully attended to. Our observation of people living in the service confirms that people are appropriately dressed and that their hair is attended to. Our checks of the bedrooms confirm that people have toothbrushes and toothpaste and records show that people see the dentist. Staff treat people with dignity and respect their privacy. Bedrooms and toilets are lockable and staff knock before entering bedrooms. We did observe staff treating people with respect and taking time to make sure that they St Mary`s Mount DS0000005003.V361878.R01.S.doc Version 5.2 Page 13 understand things they say. For example when talking to people staff knelt down to be on their level and they make sure that people are offered the meal choices. Staff we spoke to worked from the principles of ‘ treating people how they would want a relative of theirs treating’. As part of this inspection the arrangements for medication was looked at. The room where medication is kept had been cleaned and decorated since our last visit and was no longer being used as the room where chiropody was undertaken. Medication is kept securely. The service now has a system in place that enables medication audits to be completed. Records are kept of all medication received and returned. Sampling of three people living at the service show that medication is properly stored, administered and recorded. There were no gaps in the records and any times when medication has not been administered is explained. The service had some medication that needed to be stored as controlled. The service was in fact administering and recording it as controlled and our checks confirmed that the records were properly completed and the medication administered correctly. Some people are receiving PRN medication and although the service had developed individual protocols signed by the District Nurse there is in the odd situation for them to be expanded to more clearly describe the circumstances that medication is administered. Discussions with staff and examination of records confirm that staff are trained in medication and on the first day of our visit medication training was taking place. The manager also reports that some of the staff are to undertake more in-depth medication training. There is also evidence that the manager is undertaking regular audits of the medication and is completing observations of the staff’s competency to administer medication. St Mary`s Mount DS0000005003.V361878.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have the opportunity to take part in a range of activities in the service but have little opportunity to access the community. The service provides people with a varied menu that provides them with choice. EVIDENCE: The service’s plans now include information about activities and the spiritual needs of people and the service is developing plans to meet these. Records are now kept of the activities that people take part in. People have the chance to take part in a number of activities throughout the week. Three times a week an activity worker comes into the service. One session covers gently exercise and this person brings in their dog. The dog is well liked by most of the people and they enjoy interacting with it. The other two sessions cover such activities as wood games, quizzes, arts and crafts, darts, golf, boules, jigsaws, sensory sessions and gardening. People we spoke to greatly enjoy these sessions. In addition to these activities the staff at the service provide some activities including a weekly reminiscence session that can include an old film or old pictures. The service has the use of a reminiscence box from the St Mary`s Mount DS0000005003.V361878.R01.S.doc Version 5.2 Page 15 library. In addition staff do make up and nail care sessions. On the first day of our visit during the afternoon we observed staff dancing with people that live there. The service now buys two newspapers everyday and people enjoy reading these. One person is using the talking book service. An organist visits once a month and there is an ecumenical church service once a month. The hairdresser visits weekly. The service is planning to develop the courtyard as a sensory garden and one person said that they are going to help plant this. The service does need to look at how it can make sure that activities are relevant to all people including those that do not wish or are unable to join in with group sessions. Currently one area that the service could develop is supporting people to have more access to the community. A few people occasionally go out to buy clothes and personal items but most people do not leave the service. The manager did say that they are looking at organising some day trips. The service’s routines are quite flexible. People get up and go to bed when they want. People can spend time in their bedrooms or in the communal lounges. Meals can be taken in bedrooms, the lounge or the dining room. Visitors can visit at any time and several people have daily visitors. Meals were generally taken in the dining room. This was a light airy room and was welcoming. Tables had clothes and flowers. The service provides the main meal at lunchtime. Breakfast consists of cereals and toast. The service offers a choice of meals and displays the menu in the lounge. We advised that this is provided in a more user friendly way and the service completed this whilst we were there. The service told us that they offer two main meals and a salad and people can have omelettes, soup and sandwiches if they ask for them. However not all these choices were on the menu. On the day of our inspection the meals were beef stew with potatoes and vegetables or fish cake. One person was having soup and a roll. Pudding was apple sponge, ice cream, fruit or yoghurts. The meal at teatime included soup, sandwiches, something on toast followed by cakes, fruit or ice cream. Snack and drinks are available between meals and throughout the night. The service is able to provide for some special diets although for those people there is less variety. People told us that the food ‘is good’ and that there is ‘always a choice’. St Mary`s Mount DS0000005003.V361878.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are listened to and have access to a complaints procedure. Although staff are aware of signs of safeguarding issues people may not be fully protected due to some staff’s lack of knowledge of how to respond to potential incidents. EVIDENCE: The service’s complaints procedure is displayed in the hallway and a copy is provided to people with the service user guide. The service still needs to update the document with the Commission’s new address. Relatives visiting the service told us they are aware of the procedure and that if they raised issues they were responded to. However one of the questionnaires from a relative said they did not know the procedure so we would recommended that the service ensures everyone is aware of the procedure. Since our last visit there have been no complaint. The staff at the service have now received training in safeguarding people and all the staff we spoke to could tell us of the signs and symptoms that may indicate abuse. Staff are also aware that aggression and violence may be a way of people communicating distress or unhappiness. Although aware of symptoms of abuse, staff and the manager are not clear on how to respond to such concerns. They are not aware of the interagency procedures and the role St Mary`s Mount DS0000005003.V361878.R01.S.doc Version 5.2 Page 17 of the local authority in co-ordinating potential safeguarding issues. They were also not clear that a potential assault should be referred as a criminal offence. This is an area that service needs to address. The service has procedures in place to safeguard people’s money. St Mary`s Mount DS0000005003.V361878.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20,21,24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although there continues to be some areas that need to be upgraded people are provided with good accommodation overall. Bedrooms are suitable to meet people’s needs and people can make their bedroom their own. The service provides people with clean and hygienic accommodation. EVIDENCE: The service is located in a residential area of Uttoxeter. The premises are a period property surrounded in a large plot of land. To one side there is large garden and to the other a large car parking area. At the bottom of the car parking area is a building that is in the process of being developed into a day centre that is to rented by a voluntary agency. The service has a small patio area overlooking the main garden that needs some attention to make it safe. There is an enclosed courtyard but this is currently not accessible to people as it is overgrown and the paving is very uneven causing a potential hazard. The St Mary`s Mount DS0000005003.V361878.R01.S.doc Version 5.2 Page 19 service is planning to make this into a sensory garden and progress is due to start in the near future. The service had good communal sitting areas. There are 2 large lounges suitable nicely decorated and a large dining room recently decorated. The service has a small smoking room and we gave them information to check whether this met the new regulations. The service has adequate numbers of bathrooms and toilets and these have been decorated since our last visit. The service currently has 28 bedrooms, two of which are doubles. The service is currently upgrading these to make them singles with ensuite faculties. We looked at a sample of bedroom and these were adequately to meet people’s needs. Some have been upgraded and redecorated and the service has plans to upgrade all the remaining bedrooms. Bedrooms have adequate furniture including for sitting and storage. Bedrooms are personalised with people bringing in small pieces of their own furniture, pictures, photographs and ornaments. All bedrooms are lockable. The service has started to look at the environment in relation to people with dementia care needs. Some bedroom doors now have pictures on them to help people to know their own room. The manager told us that she is planning to seek advise over how she can develop the service more to meet the needs of people with dementia. The service has an industrial style kitchen and a recent inspection by the Environmental Health department awarded it 4 stars. The service has adequate laundry facilities. We saw a sample of bedrooms and these were satisfactorily furnished and decorated. The service was seen to be clean and tidy. Cleaning schedules are in place and most staff have received training in infection control. Staff were observed using protective clothing when responding to people’s personal care needs. St Mary`s Mount DS0000005003.V361878.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service provides adequate numbers of staff to support people to have their needs met. The service’s training is improving the standard of care provided to people with dementia care needs. The service’s recruitment procedure needs to ensure that it is always conducted in a way that safeguards the people that live at the service. EVIDENCE: Examination of rosters show that the service provides adequate care staffing levels to meet the needs of the people living there but needs to ensure that as the number of people increases that staffing levels are kept under review. Currently there are 4 staff on duty throughout the day during the week and 3 or 4 staff on duty over the weekend. At night there are 2 waking night staff on duty. Currently there is not a senior member of staff on duty at night although there is a senior staff member on call. We would recommend that a senior staff member be on duty to manage the nighttime care. In addition to the care staff there are ancillary staff employed to undertake the cleaning, do the laundry and do the breakfast and lunchtime catering. Issues were raised with us over adequacy of the current hours to provide the laundry service and to provide meals at teatime and we would recommend that the service review these tasks and provide additional staff if required. St Mary`s Mount DS0000005003.V361878.R01.S.doc Version 5.2 Page 21 Currently the service has 6 staff trained to NVQ level 2 or above. This is slightly less that the 50 of staff expected. The service has however greatly improved the training that staff receive to undertake their role. Since our last key inspection staff have received training in first aid, fire, food hygiene, moving and handling, medication, dementia care, safeguarding and a significant number have had training in infection control practices. Further training in dementia care practices, medication and recording is planned. The service has recently recruited a member of staff and they are currently undertaking induction training. Discussions with several staff confirm that the training they receive has improved their knowledge and skill. This is particularly evident in their knowledge of supporting people with dementia care needs. We looked at the service’s recruitment procedures by examining a sample of 3 files. All files show evidence that the service is making Criminal Record Bureau (CRB) and Protection of Vulnerable Adult (POVA) checks. The service is also checking people are who they say they are. 2 references are present on file for each person but the service needs to always make sure that it seeks the references rather than accepting them from prospective staff. The service also needs to make sure that there are no gaps in employment records. St Mary`s Mount DS0000005003.V361878.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The improvements made by the service are resulting in improved standards of care for the people that live at the service although there still remain areas that need to be addressed. The system for monitoring and reviewing the service takes account of the views of people that live at the service. The service’s health and safety practices are protecting the people that live there. EVIDENCE: The Care Manager is qualified in care and has always worked in the field of care. She does not provide any care except in an urgent situation, as the manager’s role is supernumery to the care roster. This time allows her to provide the management required to effectively run the service. She is currently supported in developing the service by a social care consultant one day a week. Since the last inspection the service had made progress and now St Mary`s Mount DS0000005003.V361878.R01.S.doc Version 5.2 Page 23 has procedures in place to provide a better service to people although there still remains areas to be developed. The manager has recently started to review and monitor care practices and care plans have been updated. These improved practices need to be maintained. There still remain areas related to making people safe that need to be addressed. The service had a Quality Assurance system in place to monitor, review and develop the service. The views of people living at the service, their relatives and staff’s views are sought once a year. Records ware present to confirm that these surveys are completed and actions taken to address any issues from them. Additional audits include assessing the competency of staff to undertake medication; weekly medication audits, environmental assessments, and monthly care plan audits. Information from these audits plus information from staff meetings and the Responsible Individual’s inspections inform the service’s business and development plan. There was scope for the service to seek the views of professionals to feed into the quality assurance system. The service is not the appointee for anyone living at the service but did look after money for some people. A check of a sample of this confirms that money is kept securely and that receipts support expenditure. The checks we did show that the records and the cash held balanced. Since the last key inspection staff have had training in Health and Safety practices including food safety, first aid, fire, moving and handling and infection control. The service is completing checks of fire equipment and has completed its evacuation procedure including the support each person needs should they need to leave the building in an emergency. The service told us that they had responded to the recommendations made by the fire authority. St Mary`s Mount DS0000005003.V361878.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 X X 3 X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 St Mary`s Mount DS0000005003.V361878.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP8 Regulation 13(4) Requirement Where people are using bedrails a system must be put in place to make sure they are fitted and maintained properly. This will make sure people are protected. Staff must know how to how to respond to safeguarding issues. This will ensure that any issues are dealt with properly and improve people’s protection. The service’s recruitment procedures must ensure that all checks are always properly completed in order to safeguard people living at the service. Timescale for action 16/05/08 2. OP18 13(6) 01/06/08 3. OP29 19(1)(c) 15/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP1 OP7 Good Practice Recommendations To provide information in different formats so that it is more accessible to people. To ensure that people are involved in developing their own DS0000005003.V361878.R01.S.doc Version 5.2 Page 26 St Mary`s Mount 3. OP7 4. 5. 6. 7. OP8 OP9 OP9 OP12 care plans. This will make sure that plans include how people want their care to be provided. That the service further continue to develop its person centred planning particularly for people with dementia care needs. This will make sure that staff are fully aware of people with individuals needs and experiences. Suitable systems must be in place to accurately monitor people’s fluid intake. This will make sure that people have sufficient fluid throughout the day It is recommended that the staff undertake the ‘Safe Handling of Medicines’ training. To further develop medication protocols so that there is always consistency over when medication is administered. To listen to the people who use the service and to relatives and develop activities internal & external to the home including those suitable for people with dementia. To make sure that the menu identifies all the food available. This will make sure that people are aware of all the choices available to them. To look at providing a greater choice of meals including for people with a diabetic diet. To clear and make safe the internal courtyard and the patio for people to access To continue to upgrade and decorate the bedrooms so that all bedrooms are of a high standard. The service to look at environmental changes to assist people with dementia to become orientated. To keep the service’s care and ancillary staffing levels under review in order that adequate staff are on duty to meet people’s needs. To increase the number of staff qualified to level 2 NVQ in order to provide a higher standard of care. 8. 9. 10. 11. 12. 13. 14. OP15 OP15 OP19 OP19 OP19 OP27 OP28 St Mary`s Mount DS0000005003.V361878.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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