Inspection on 11/03/09 for St Mary`s Nursing Home

This inspection was carried out on 11th March 2009.

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

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

Other inspections for this house

St Mary`s Nursing Home 12/03/07

St Mary`s Nursing Home 21/01/06

St Mary`s Nursing Home 19/09/05

St Mary`s Nursing Home 20/12/04

St Mary`s Nursing Home 26/07/04

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 15/11/2009.

CARE HOMES FOR OLDER PEOPLE St Mary`s Nursing Home Montilo Lane Harborough Magna Rugby Warwickshire CV23 0HF Lead Inspector Suzette Farrelly Key Unannounced Inspection 11th March 2009 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 Nursing Home DS0000004410.V374531.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 Nursing Home DS0000004410.V374531.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary`s Nursing Home Address Montilo Lane Harborough Magna Rugby Warwickshire CV23 0HF 01788 832589 01788 832216 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) Mr Simon Northover Mrs Beatrice Gooch Ann Manklow Care Home 77 Category(ies) of Dementia - over 65 years of age (28), Old age, registration, with number not falling within any other category (49) of places St Mary`s Nursing Home DS0000004410.V374531.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The Registered Manager must undertake and complete the Registered Managers Award by January 31st 2007. The Registered Manager must attend some accredited dementia training by December 31st 2005. Within the total of 77 beds St Mary’s may also care for up to five service users between the ages of 55 to 64, who’s nursing or social care needs outweigh age considerations. 12th March 2007 Date of last inspection Brief Description of the Service: St Mary’s care home is set in its own grounds near to the village of Harborough Magna, 5 miles from Rugby. The care home has been developed from the old maternity hospital, and retains some of the character. St Mary’s care home is registered for frail elderly, and older people with dementia. Intermediate care beds are provided to enable rehabilitation for people prior to returning to their own home. The accommodation is purpose built and is on two floors with all rooms being single en-suite. There is a shaft lift to the first floor and adequate assisted bathing facilities. The environment meets the National Minimum Standards. The home offers a service for people with a range of physical and dementia care needs. . Care is provided by qualified nurses and care staff that have received training in dementia care. There is a small terrace from the dining room, where service users can sit out, looking across open land. Due to the rural situation the nearest village is approximately 1 mile away. Public transport to the home is limited. Fees for residence at St. Mary’s are £500 - £580 per week. St Mary`s Nursing Home DS0000004410.V374531.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This service has been awarded a 1 Star Rating. This means that the service is adequate. The service did not know we were coming to the home to carry out an inspection; this is referred to as an unannounced inspection. We visited on two separate days so that we could meet with the registered manager. The purpose of these visits is to establish how the home in functioning and the outcomes for the people using the service. We also check that the practices are safe and that staff understand how to recognise abuse and report this appropriately. Our process is to look at all the information we have about this service such as information from other professionals, surveys from people using the service, notification from the home about incidents, accidents and other things that happen that affect the people who live there and the home. At the home we ‘case track’ four people, this involves reading their care records, taking to staff, and discussing the care with the person if this is possible about their experience of their care. We look at other documents which assist us to make a decision about the level of risk to the people living at the home through the care practices and management of health and safety. During this visit we spoke to people using the service, relatives, staff and senior management. This gave us an overview of the service and enabled us to make a judgement and award a star rating as shown above. This was rated as a 2 Star service, it was found at this inspection that some areas of care and management did not ensure that there are good outcomes for all the people using this service and therefore a new rating has been awarded. The people spoken to were satisfied with the care they received the people in the Dementia Care Unit. could not share their experiences due to communication difficulties, we therefore observed how staff interacted with the people and how their needs were met. What the service does well: St Mary`s Nursing Home DS0000004410.V374531.R01.S.doc Version 5.2 Page 6 The planning of care on the General Unit is good and this ensures that all staff have the information needed to meet the needs of each person in the way they wish. Medication storage and administration was good on the general unit and the member of staff spoken with was aware of her responsibilities. Staff are trained to carry out their roles and can meet the needs of the people they care for. The home is clean, free from unpleasant smells and safe for the people who live there. In the summer there are garden parties and the staff raise money for the residents fund and the Alzheimer’s Society. The relatives and people using the service are asked what they would like to do with this money. There is good management of skin and the service has no one with a sore developed from pressure. There is a good relationship with the local surgery, they visit twice a week and good concise records are maintained. There is a good choice of meals at lunch time and these are presented well. There is suitable equipment for the people to use such as profiling beds, hoists, equipment to improve mobility. The qualified staff undertake training to keep their skills and ensure they are up to date and safe to give nursing care. People using the service told us ‘The staff are good’ ‘The help me when I need it’ ‘It’s OK here’ What has improved since the last inspection? What they could do better: St Mary`s Nursing Home DS0000004410.V374531.R01.S.doc Version 5.2 Page 7 The planning of care in the Dementia Care Unit should be more person centred and describe in more detail how staff should respond to each person to ensure that their needs are met appropriately and in the same way by all staff. The pre-assessment of people before admission should be more detailed so that the service can show that they have considered all the needs, equipment required and staffing hours needed to meet the needs and that they are able to meet these. The management of medication must improve; the qualified staff must ensure that all medicines are checked and that any medicines that are prescribed for ‘when required’ are within the expiry date and still needed. Daily records must be completed during each shift to ensure that there is a running record of the daily activities, actions taken by staff and how each person has experienced their day. This ensures that all staff have the information to determine if changes in care is required. The activities available to all people living at this service needs to be improved. Meals at tea time need to be improved and the practice of liquidising all food items together should stop. The policies and procedures in relation to safeguarding must be available to all staff to ensure that they are fully aware of the actions to take when required. Some areas of the home are not homely and lack comfort, the senior management need to assess this and decide how best to achieve a more homely and comfortable spaces. 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 Nursing Home DS0000004410.V374531.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 Nursing Home DS0000004410.V374531.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): 3, standard 6 does not apply. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People can not be completely satisfied that their needs can be met by the service before admission as the pre admission assessments are incomplete. EVIDENCE: Three peoples were records were seen, these told us that the information completed before admission would not ensure that the staff would be able to ensure that all needs can be meet. There was clear indication in one pre-admission assessment that the person’s life had been seriously impacted by their condition. There was no information to say how this had impacted or what the family had done to minimise this. St Mary`s Nursing Home DS0000004410.V374531.R01.S.doc Version 5.2 Page 10 Social Service assessments and Medical request assessments were seen, these were dated the day of admission, this would not give the service time to assess the needs of a person and ensure that they would be able to meet them. One person had a Continuing Health Care Assessment that told us that this person was able to make decision but had some confusion and could be agitated in the evenings. There was no further exploration of this, such as the presentation of the agitation and actions that may relieve this. Pre-admission assessment should contain sufficient information to ensure that the management and staff can make an informed decision that they are able to meet all the needs of the person in a way that suits them. The service encourages people to visit before admission, this does not occur very often as many of the people admitted come directly from hospital and arranging a visit is not easy. The management must ensure that all people, before admission are given the opportunity to visit if possible or given suitable information that will tell them about the service. Some relatives visit before admission and make the decision to accept admission on behalf of their relative. St Mary`s Nursing Home DS0000004410.V374531.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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each person can not be confident that all their needs will be met as they would wish and that the management of medication is not robust enough to protect them from mistakes. EVIDENCE: Four care profiles were examined, two from the dementia care unit and two from the elderly frail unit. It was found that the care profiles from these two units vary and the information available is good from the elderly frail unit and the information recorded on the dementia care unit does not contain sufficient information. The care profiles on the dementia care unit contained risk assessments and plans of care. The risk assessments had been reviewed monthly, any changes St Mary`s Nursing Home DS0000004410.V374531.R01.S.doc Version 5.2 Page 12 were recorded and the previous situation crossed out. This could cause confusion. The care plans were basic and not person centred, this is where the plan talks about that person and what they need to assist them or to work with them, they also lacked depth of information which would assist staff to be consistent in their care and approach to each person. One plan read told us that the person could be agitated in the evening and staff were to ‘reassure him’, there was no further information stating how this was to be done. The care plan of another person stated that they were not ‘orientated in place or person’; this means that they were confused about where they are and who they are speaking to. The plan did not give clear instructions on how this should be managed. It was observed that staff agreed with this person but did not use other techniques that are available. The daily records, which record the day to day activities of each person, were not consistently maintained; as many as three days in a row were missing. This would make it more difficult to determine if the care and support is working. One persons care plan stated that they needed to be fed in the lounge to reduce stimulation and a member of staff needed to stay with them. This did not happen and when asked the staff told us this was no longer required. This showed that not all care plans are up dated when needed. The care profiles in the elderly frail unit were good, these contained clear risk assessments and the care plans were detailed and gave sufficient information for the staff to know what they needed to do. The daily records are clear and completed twice a day, giving information about the health and well being of each person. The service used a ‘bath book’ which details when each person is bathed, and when the beds are changed. This information told us that a person in the dementia care unit had not had a bath for 24 days and the bed was change only twice in the month. There was no written information to show that the nurses or the lead for the unit had checked this. Staff spoken to in both units were aware of their roles and were able to tell us the care that they give to each person discussed. This did not always correspond with the written care plans as stated earlier. A person on the elderly frail unit told us, that ‘the staff respond well and assist me the way I want’ and ‘she is happy with the care’. St Mary`s Nursing Home DS0000004410.V374531.R01.S.doc Version 5.2 Page 13 Medication management and administration varied across the units. The medication is administered from a trolley on the elderly frail unit and the nurse was observed to do this safely. On the first day of the visit time was spent looking at medication on the dementia care unit. It was noted that the medication was in a locked room on open shelving, on the second visit, cupboards had been assembled as required. The staff were still moving medication from one box to another this is poor practice and a requirement had been made previously. Again this had been addressed at the second visit. The medication administration records were completed for each administration, the quantity of medication available was difficult to determine due to the way this was recorded. There was no written information to tell us that medication is audited to ensure that there is a correlation between medication dispensed and given. One person on the elderly frail unit was self medicating; this was checked and found to be managed well. The person knew what medication they took and explained where they kept this. A risk assessment was available and the qualified nurse was able to tell us how this is managed. St Mary`s Nursing Home DS0000004410.V374531.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 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each person can not be assured that their lifestyle needs are met at all times and that they are satisfied both socially, culturally, religiously or through recreation. EVIDENCE: The manager told is in the AQAA that they provide a high standard of meals and that they use ‘Getting to Know You’ forms to help the service develop suitable activities and to ensure that each persons needs are met. There was a varied picture of activities in the service. The dementia unit was visited on two separate days and there was no organised activity occurring. It was noticed that there were no newspapers, magazines or other items available for the people to use. An activity box was seen behind a door and was not accessible. St Mary`s Nursing Home DS0000004410.V374531.R01.S.doc Version 5.2 Page 15 Most of the people on this unit were either walking around or sitting in various rooms in the unit. Staff did not appear to have time to sit and talk or do any form of activities. The meal times were noisy, poorly organised and demanding on staff. There is a high dependency on this unit and over half of the people living there require assistance with eating. This means that the people in the dinning room are given less assistance and sometimes left for short periods alone. The people were brought into the dinning room at least 20 minutes before the meal was served, on the first visit there was no evidence that it would soon be tea time. There was no table clothes, cutlery or any other signs of a meal. People became restless and agitated, the level of noise increased. People got up to leave and were repeatedly told to sit back down. On the second visit table clothes were available and table mats and during lunch people were asked what they would like and given time to answer. There was still a high level of noise and the staff still rushed from one person to another. The tea time meal was not well presented and for those people requiring a liquidised diet, the food had been liquidised together. This means that the person can not see what they are eating and the taste and texture would be the same. The cook told us that at lunch time all items are liquidised separately, but as the care staff completed the evening meals this is not done. The elderly frail unit, many of the people on this unit either need special diets or are bed bound, some so eat in the lounge. The end of lunch time was observed and the people seemed relaxed and calm and there was light music playing. One person told us that the food was nice and she always was given a choice of meals. There were limited activates in the elderly frail unit during the visit made on the second day. There are two activity organisers employed by the service, these both often work as carers, this is impacting on the activities available to people living there. There is information about garden parties in the summer, outings to the garden centre and eating fish and chips. Visitors can visit when they choose, one relative spoken to told us that she is always made welcome and that she can stay for as long as she wishes. Relatives are also asked if they wish to be involved in outings. St Mary`s Nursing Home DS0000004410.V374531.R01.S.doc Version 5.2 Page 16 The Catholic Church visit once a week, there are no representatives from the Church of England. Some staff have completed training in equality and diversity, however, care planning, activities and the approach of staff suggests that this needs addressing. St Mary`s Nursing Home DS0000004410.V374531.R01.S.doc Version 5.2 Page 17 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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People can be assured that their concerns and complaints will be listened to and dealt with. Adult protection information is insufficient to assure that all safeguarding matters would be dealt with robustly. EVIDENCE: There is a clear complaints policy and procedure which is available in the service user guide and in the reception area. We have not received any complaints and the service has received one which is being investigated by the manager. The records of complaints were available and it showed that the manager and senior staff deal quickly with any concerns raised. One person at the home told us that they had not needed to complain but would tell the qualified nurse if there was an issue. The policies and procedures relating to the protection of vulnerable adults is not robust. There is a policy explaining abuse in line with ‘No Secrets’. There are no policies and procedures in relation to reporting abuse, actions to be taken once reported, and Whistle Blowing. These are required to ensure that all staff know what is expected of them. St Mary`s Nursing Home DS0000004410.V374531.R01.S.doc Version 5.2 Page 18 Staff spoken to told us what ‘abuse’ means to them and this is in line with local and national information. They also told us what they would do if they witnessed or were informed of abuse. Staff were less sure about managing aggression and violence between people living at the service. At the second visit we had been informed of a safeguarding which had been reported to the manager involving a member of staff. It had not been reported at the time of the incident and this could have resulted in further abuse. The member of staff has been suspended and the manager has reported this to the local authority that has responsibility to investigate. The employment of staff is robust and all checks are carried out this ensures that they are suitable to work with vulnerable people. Each person’s money is handled appropriately and good records are maintained. St Mary`s Nursing Home DS0000004410.V374531.R01.S.doc Version 5.2 Page 19 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person can be confident that they live in a comfortable, safe and pleasant environment that meets their needs. EVIDENCE: The service has two floors; the ground floor is used for people with dementia. The area has recently been decorated, the provider told us this was in line with recent research. It was noted that further work is required to ensure that the décor is appropriate in all areas. There are pictures on the walls that can be touched nod have different textures. Three people on the unit were showed these and found them interesting. St Mary`s Nursing Home DS0000004410.V374531.R01.S.doc Version 5.2 Page 20 The dining room in this area is bland and not comfortable; on the second visit the manager had alter some areas of this room, new table clothes had been purchased and the room looked more cheerful. Each person has there own room, some of these were seen, they had a variety of personal affects, which makes this space homely and familiar for the person. One person show us their room, and told us that they liked it. All bedrooms were unlocked. The elderly frail unit was clean and tidy and the individual rooms again had personal items belonging to the individual. One room was seen with no personal items, the nurse informed us that this person had no relatives, the management should consider how rooms can be personalised for those in this situation. Both areas have separate sitting and dining areas with a variety of seating to meet the needs of the individuals living there. There are also assisted bathrooms available. The service is clean and staff were seen to use appropriate protective clothing when needed. St Mary`s Nursing Home DS0000004410.V374531.R01.S.doc Version 5.2 Page 21 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, and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person can be confident that they are cared for by trained staff who are suitable to work with them. EVIDENCE: Five staff records were looked at and this confirmed that all checks are carried out to ensure that they are suitable to work with vulnerable people. Each new employee has a work based induction that is in line with the skills council standards; they are also given a book on abuse and the General Social Care Council’s standards for carers and employers. All nursing staff have had their PIN number checked with the Nursing and Midwifery Council to ensure that are registered to nurse. Other training in up to date and the service has commenced training in Deprivation of Liberty Safeguarding [this relates to the rights of each person and that there is no unnecessary restraint to their lives]. The qualified staff have also undertaken short training for various techniques needed in the care of more dependant people. St Mary`s Nursing Home DS0000004410.V374531.R01.S.doc Version 5.2 Page 22 There is sufficient staff on duty at each shift. As stated earlier the two activity organisers often work as carers to cover when there are gaps. It was noted that meal times on the dementia unit is very busy and there are insufficient staff to ensure that this is a good experience. The management should consider how this can be better managed. The home employs ancillary staff for cleaning and maintaining the service. There is also administration support available. St Mary`s Nursing Home DS0000004410.V374531.R01.S.doc Version 5.2 Page 23 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, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each person can not be always confident that the home is run to ensure the best outcomes for them. EVIDENCE: The manager has worked at this service for many years and is aware of the structure and actions required to ensure that this is run well. The AQAA was returned to us as required, the information did not tell us all we needed to know and this needs to improve. St Mary`s Nursing Home DS0000004410.V374531.R01.S.doc Version 5.2 Page 24 The deputy manager works part of the time as a senior carer in the elderly frail unit and therefore has a dual role. It is not clear who has responsibility for which areas of management; this could lead to confusion or things not being carried out. An assessment of this is required and a plan put into place. The supervision of staff has not been taking place, it is required that the service demonstrate that staff are supervised and given the opportunity to explore what training needs they require. The manager told us that they planned to re-start the supervision in April but this had not been finalised. The service does not manage the monies of the people living there. All items are purchased for them and the family are invoiced. This is agreed at admission, and a limited the amount spent on one item is agreed. One person who has no relatives receives support from an advocate from age concern. There was limited evidence that a full quality system is in place to ensure that the service is run to the best interest of the people living there. There are no audits for the medication, care profiles, admission procedures, the experience of those using the service. The provider should consider how this can be achieved. The Environmental Health awarded the kitchen a Gold Star Award in April 2008, which is Very Good to Excellent. A sample of certificates for the maintenance of equipment was checked and this told us that these are up to date. St Mary`s Nursing Home DS0000004410.V374531.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 1 X 3 St Mary`s Nursing Home DS0000004410.V374531.R01.S.doc Version 5.2 Page 26 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 OP8 Regulation 12 (1) Requirement Ensure personal care profile recording is completed daily. To ensure that there is a record of health and well being to assess with ensuring that the care and assistance given is current. 2 OP9 12[2] Secondary dispensing of medication must stop. This is poor practice and does not safeguard the people from harm. 3. OP12 15 & 16(2)(n) Provide suitable activities for residents on both units daily and provide clear records of activities. This is to ensure that each person is occupied is a way that suits them and they are assisted to meet their social and interest needs. 4. OP12 16(3) Ensure appropriate pastoral care is available to all residents. DS0000004410.V374531.R01.S.doc Timescale for action 31/05/09 31/05/09 30/06/09 30/06/09 St Mary`s Nursing Home Version 5.2 Page 27 So that each person has their spiritual needs met to create peace. 5 OP18 13 There must be policies and procedures for the reporting of issues of safeguarding that meet with National and Local guidelines and a Whistle Blowing policy must be available. This is to ensure that staff are fully aware of actions to take and their rights. 6 OP33 24 Further develop suitable quality assurance and monitoring system with results available to all. To demonstrate that the service is run in the best interest of the people who live there. All qualified and care staff must have formal supervision. This will ensure that they have suitable skills and that practice continues to be safe. 31/05/09 31/05/09 7 OP36 18 31/05/09 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 OP27 Good Practice Recommendations An assessment of staffing hours required at all times of the day should be undertaken and actions taken where more staff are required. Risk assessments should be re-written when there are DS0000004410.V374531.R01.S.doc Version 5.2 Page 28 2 OP8 St Mary`s Nursing Home changes to ensure that this is clear avoiding mistakes. 3 OP9 The administration of medication on the dementia unit should be assessed to ensure that the transport of medication from the cupboard to the person is safe. St Mary`s Nursing Home DS0000004410.V374531.R01.S.doc Version 5.2 Page 29 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. Extracts may not be used or reproduced without the express permission of CSCI St Mary`s Nursing Home DS0000004410.V374531.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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