Inspection on 11/09/07 for St Mary`s Residential Care Home

This inspection was carried out on 11th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 Residential Care Home 16/05/06

St Mary`s Residential Care Home 07/11/05

St Mary`s Residential Care Home 24/05/05

St Mary`s Residential Care Home 14/10/04

St Mary`s Residential Care Home 27/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE St Mary`s Residential Care Home 14 Westbrooke Worthing West Sussex BN11 1RF Lead Inspector Mrs A Peace Unannounced Inspection 11th September 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Mary`s Residential Care Home DS0000014738.V344892.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 Residential Care Home DS0000014738.V344892.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary`s Residential Care Home Address 14 Westbrooke Worthing West Sussex BN11 1RF 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) 01903 233523 david@stmarysworthing.org Institute of our Lady of Mercy Mr David Chadwick Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places St Mary`s Residential Care Home DS0000014738.V344892.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th May 2006 Brief Description of the Service: St Mary’s Care Home is a home for older people registered to accommodate up to twenty-five residents over the age of 65 years. It is a large detached property arranged on three floors situated in a quiet residential area of Worthing. Accommodation is provided in twenty-five single rooms all with en-suite and shower facilities. There is a large sized garden at the rear of the property. Facilities include two lounges, a sun lounge, a conservatory and a dining room. The service is owned by The Sisters of Mercy and the manager is Mr David Chadwick. The fees at the home range from £425-£475. St Mary`s Residential Care Home DS0000014738.V344892.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mrs Ann Peace Regulatory Inspector carried out this unannounced key inspection on 11th September 2007. This is the first inspection for the year 2006-2007. It is called a key inspection and will determine the frequency of visits/inspections hereafter. Prior to the inspection, records and information held on file were reviewed. The manager Mr Chadwick was not present for the inspection but the deputy manager was managing the home in his absence. Mr Chadwick had completed an annual quality assurance assessment and sent it back to the Commission in good time for it to inform us what was happening in the home and how they were meeting the needs of residents. During the visit we toured the building, visited residents in their rooms and in the communal areas. A case tracking exercise was undertaken for a number of residents. The tracking exercise looked at records and tracked the records to the care given for individual needs identified. The records are clear and well maintained. Staff recruitment and training records were also examined and found to be well maintained and confirmed that staff are receiving the training they need to care for older people. Through observation, taking account of what residents and their relatives said in the satisfaction surveys and by speaking to staff and residents we formed the opinion that staff give an excellent standard of care, and communication between staff and management is good. However Mr Chadwick has not yet applied to the Commission to be registered as manager of St Mary’s. Some of the comments in the surveys were; “Every thing in the home is lovely, staff and other residents are happy and friendly there is a lovely atmosphere when you arrive”. “The staff respond in a caring and professional manner and during a recent bad time staff exceeded expectations”. “Staff are very caring and attentive, thoughtful and aware of residents needs”. “I have been very impressed by the level of staff support. There is a good balance of inclusion and privacy. Residents are encouraged to have their say at meetings and their views are taken into account”. St Mary`s Residential Care Home DS0000014738.V344892.R01.S.doc Version 5.2 Page 6 We concluded that St Mary’s provides excellent care from a caring and committed staff team. What the service does well: What has improved since the last inspection? Training for staff has improved and all staff have had updates in safeguarding people. A new dining room floor has been laid and new dining room furniture purchased. A new large screen television with added speakers has been purchased and a computer terminal for the use of residents has been provided. The supper menus are being changed following requests from residents and the laundry system has been changed also as a result of a resident’s satisfaction survey. The time of morning mass has been changed to enable residents more time for organised and personal activities. The care records have been transferred to a computer system and senior carers and key workers have been appointed and trained to improve the continuity and personalised care for residents. St Mary`s Residential Care Home DS0000014738.V344892.R01.S.doc Version 5.2 Page 7 A new activities co-ordinator has been employed allowing improvements to be made to the activities programme. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Mary`s Residential Care Home DS0000014738.V344892.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 Residential Care Home DS0000014738.V344892.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): 1,3,4,5,6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives have good information to be able to make an informed decision about the home. All residents are assessed before admission to ensure the home will be able to meet their needs and trial visits are encouraged. The home does not offer intermediate care. EVIDENCE: The statement of purpose and service users guide for the home which explains about the home and the service they offer was on display in the home and had been recently updated. The majority of people who filled in satisfaction surveys said they had received enough information about the home to make a decision. St Mary`s Residential Care Home DS0000014738.V344892.R01.S.doc Version 5.2 Page 10 Since the last inspection care records have been transferred onto a computer system which staff access on a daily basis. The assessments of four residents were seen on the computerised system and although the main points have been transferred from hard copies, not all information about past medical and social history has been completely transferred over. We were told that this process was still going on. Pre assessments are always carried out before a residents is offered placement and it is on the understanding that the first four weeks is a trial period for the resident to decide if the home is right for them and the home to be sure they will be able to meet the resident’s needs. Respite care is offered at the home but there are no facilities for intermediate care. St Mary`s Residential Care Home DS0000014738.V344892.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): 7,8,9,10,11.Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents have up to date care plans and risk assessments and care staff look after residents to an excellent standard. Policies and procedures are in place for medication administration and staff are well trained and noted to adhere to safe practice. Staff work hard to make the home safe, comfortable and a nice place to live for the residents. Respect, privacy and dignity are high in the agenda in the home and the staff were noted to adhere to this philosophy. Ay time of death residents and their families and friends are well cared for and supported by a caring staff team. EVIDENCE: St Mary`s Residential Care Home DS0000014738.V344892.R01.S.doc Version 5.2 Page 12 The deputy manager was on duty on the day of the visit and when we spoke to her she was knowledgeable about all of the residents and the care they needed. All residents have up to date, detailed care plans which clearly tell staff what care is needed for the resident, these are now kept on the computer which care staff have access to on a daily basis. Senior staff have a different level of access to junior staff and are responsible for updating and keeping the records in order. The programme reminds staff when various risk assessments and monitoring assessments are due. Daily records for all residents are maintained so staff are aware of the ongoing condition of the residents and various staff were seen to update the records throughout the visit. Senior staff re-assess residents on a monthly basis with the residents if they want to be involved and their key worker. Risk assessments are in place which identify what are the risks to the residents and the action staff are to take to minimise harm. These included risk to pressure areas, nutritional risks and risk of falls. Specialist equipment is in place throughout the home to enable residents to mobilise safely, to promote independence and for staff to care for residents safely. Records showed that health professionals such as district nurses, GP’s and other specialist health professionals are contacted promptly when needed in the home. During the visit staff were noted to treat the residents in a respectful but caring and friendly way. Residents were at ease with the staff. Staff were seen to encourage residents to make choices throughout the day which indicated that residents do have independence, choice and control over their lives. Staff knocked on doors and waited before entering a resident’s room which respected resident’s privacy. We concluded that at the time of death it would be handled with care, sensitivity and respect and relatives and friends would be well supported. Proper arrangements are in place for the safe administration of medicines and staff receive training in this. Part of the medication round was observed and the member of staff followed safe practice. Senior staff and others who want to take part are presently going through a 12-week safe medication administration course. Residents can look after their own medication if able and staff re assess them on a regular basis to ensure they are still able to manage. All areas of the home are covered by a call bell system and residents spoken to say they are always answered promptly. St Mary`s Residential Care Home DS0000014738.V344892.R01.S.doc Version 5.2 Page 13 All senior staff and some other staff in the home have attended a four-day first aid course, we were told that there is always someone on duty who can administer first aid. The satisfaction surveys returned to the Commission were all very complimentary about the staff and the care they give. From looking at records, speaking to residents and from satisfaction surveys we concluded that an excellent standard of care is provided by a skilled well trained and caring staff team. Some comments were: “The home makes my father feel welcome and at home and the staff at the home are caring and attentive”. “Every thing in the home is lovely, staff and other residents are happy and friendly and there is a lovely atmosphere when you arrive”. “The staff respond in a caring and professional manner and during a recent bad time staff exceeded expectations”. “Staff are very thoughtful and aware of residents needs”. “I have been very impressed by the level of staff support. There is a good balance of inclusion and privacy. Residents are encouraged to have their say at meetings and their views are taken into account”. St Mary`s Residential Care Home DS0000014738.V344892.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 excellent. This judgement has been made using available evidence including a visit to this service. The routines of daily living are flexible and residents are encouraged to be independent. Residents are entertained and stimulated through an activities programme of their choice and visitors are welcomed into the home. Residents are encouraged to make decisions about their welfare and are entitled to bring personal possessions into the home. Residents are served high quality, varied, appealing, wholesome food. EVIDENCE: Through talking to residents, staff and by reviewing the satisfaction surveys and care records we concluded that the routines of daily living and activities in the home are flexible and suit residents expectations and preferences. The home has a calm and relaxed atmosphere and although there is a strong religious ethos throughout the home and mass is said daily in the lovely chapel, residents told us that they can do what ever they wish and are not St Mary`s Residential Care Home DS0000014738.V344892.R01.S.doc Version 5.2 Page 15 pressured in any way to take part and that their own religious persuasion was always respected. The home employs an activity co-ordinator who is developing an activities programme to suit residents. Some activities provided are Songs of Praise, gentle yoga, quizzes, bingo and film nights. Photographs of social events held at the home are on display in one of the corridors. There has recently been a BBQ to celebrate the retirement of one of the sisters who worked at the home. There are two lounges and a conservatory for residents to relax in; one lounge has a large screen TV with added speakers around the room for those residents who have difficulty hearing. The satisfaction surveys said that residents were satisfied with the activities presently on offer although some residents prefer to have a quiet life and not take part. Since the last visit a computer terminal for residents to use has been purchased and is in one of the lounges. Residents are free to come and go as they wish and this was noted throughout the day of the visit. As the home is only a short walking distance away from the town centre some residents often go into town to do their own shopping. Staff do take other residents who wish to go out but cannot go independently. Safe, well-kept and enclosed gardens surround the home there is plenty of seating for residents and some residents were using the gardens to sit and chat during the visit. The time of morning mass has been changed to enable residents more time for organised and personal activities. There is a pleasant homely dining room which was nicely set out for the lunchtime meal. The majority of residents do go to the dining rooms for meals, however they did tell us that it is their choice. Residents help themselves from serving dishes although staff were noted to be on hand to help those who needed it. The lunch was a sociable occasion and was unhurried; a choice of meals of roast chicken or lamb casserole with potatoes and fresh vegetables was available. This was followed by rhubarb and apple crumble with custard and cheese and biscuits. The lamb meal was sampled and was delicious. Residents told us that the chicken meal was also very tasty. Menus seen indicated that a balanced diet is being provided and the majority of satisfaction surveys were positive. Where there were comments made it was about the supper menu. St Mary`s Residential Care Home DS0000014738.V344892.R01.S.doc Version 5.2 Page 16 However following a recent resident’s meeting where this was discussed, on the day of the visit the supper menus were being changed to take into account what residents said they wanted. Residents spoken to said staff were very respectful and did protect their privacy and all residents spoken with and who completed the surveys said the lifestyle in the home suited their needs. The social history and past interests have not yet been transferred to the computer system for all residents so all of the records on the system are not complete. This was discussed with the deputy manager who said this was presently being done. St Mary`s Residential Care Home DS0000014738.V344892.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): 16,17,18. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. There is a clear accessible complaints procedure which indicates that complaints would be taken seriously and investigated. Resident’s legal rights are protected. Staff are trained to ensure residents are safeguarded against abuse. EVIDENCE: There is a clear complaint procedure; a copy is displayed in the home. All of the surveys said that people would know who to complain to. Residents spoken to say they would feel confident to complain if they had to. The deputy manager was advised to record all complaints however minor so that they can be audited as part of the quality assurance system. Residents have their legal rights protected; residents were given postal voting forms for the forthcoming elections and a number of residents were taken out to vote at the last election. Advocacy services are available and the Statement of Purpose stated that home would access the service for residents who needed it. St Mary`s Residential Care Home DS0000014738.V344892.R01.S.doc Version 5.2 Page 18 Training in safeguarding adults is mandatory at the home and all staff have received training. We asked a number of staff what they would do in the event of abuse being suspected and they were all clear of the correct procedure to take. The home’s policy for safeguarding adults is in the process of being updated, however the new safeguarding adults policy for West Sussex is available in the home for staff to access. St Mary`s Residential Care Home DS0000014738.V344892.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): 19,20,21,22,23,24,25,26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, homely and well-maintained environment and have access to safe indoor and outdoor communal accommodation. Furnishings and decoration are of a high standard. Residents have sufficient toilets and washing facilities and have specialist equipment to meet their needs. Residents live in safe comfortable bedrooms with their own possessions around them. The home is clean, hygienic and pleasant. EVIDENCE: St Mary`s Residential Care Home DS0000014738.V344892.R01.S.doc Version 5.2 Page 20 The home is situated in Worthing not far from the town centre, some parking is available. The exterior and interior of the home are well maintained and the gardens well kept. There are safe pathways for residents to use and residents using mobility aids would be able to access the gardens safely, there is also a ramp available. Seating is available at points around the gardens. The home is homely, clean, tidy, and free from offensive odours. The furnishings and decoration are kept to a high standard and the home is well maintained Bedrooms and communal rooms are decorated and furnished to a high standard but are still homely and comfortable. All bedroom doors have locks on them and residents can choose whether to lock their door for privacy should they wish. Bathrooms are roomy, have specialist aids to keep residents and staff safe, and are hygienic and fresh. Pictures and other items of interest are around in the corridors of the home which adds to the homely atmosphere. The history of the home which was a hospital during the wars is on display along with old photographs. Since the last visit the dining room floor has been replaced and new furniture has been ordered. There is a beautiful chapel in the home which has large stained glass windows; staff and residents can access the chapel whenever they wish. When talking to residents and by conducting a survey the management of the home identified that there were minor problems with the laundry service so new systems for organising the laundry service have been planned and some already carried out, we were told by residents that things are now better. St Mary`s Residential Care Home DS0000014738.V344892.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): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by the numbers and skill mix of staff. Staff are well trained to look after residents and keep them safe and the recruitment process is robust and protects residents. EVIDENCE: The duty rotas indicated that there is sufficient staff on duty with the correct skill mix to meet the needs of the residents accommodated over a 24-hour period. This was also evidenced by talking to residents and by the satisfaction surveys returned to the Commission all of which indicated that there was enough staff on duty when they needed them. On the day of the visit the deputy manager was in charge of the home and was able to assist us when looking for evidence through the records. Care staff are supported by a sufficient number of ancillary staff. We were told that at night there are always two carers on duty awake and one senior member of staff as a sleep in for extra support should it be needed. Duty rotas confirmed this. St Mary`s Residential Care Home DS0000014738.V344892.R01.S.doc Version 5.2 Page 22 Recruitment records for new staff were examined and all contained the safety checks required by legislation and that would ensure residents are safeguarded. 78 of staff have achieved National Vocational Qualification level 2 or above and more staff at the home are undertaking NVQ qualifications. Staff told us they are encouraged and well supported to attend training courses. Training includes: manual handling, adult protection, first aid, COSHH, health and safety, food handling. Residents when spoken to and from replies in satisfaction surveys said staff knew how to care for them and they were very happy with the care given by the staff, they thought they had the skills and training to do their work. St Mary`s Residential Care Home DS0000014738.V344892.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): 31,32,33,35,36,37,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has shown he is competent to run the home to the benefit of residents and staff but has not yet applied to become registered with the Commission. It could be demonstrated that the staff are trained to a good standard in caring for older people and that they are committed to ensuring the health welfare and safety of residents. Resident’s benefit from the open leadership and management approach in the home and the home is run in the best interest of the residents. A staff supervision and appraisal system in operation. A quality assurance system is in operation in the home and the views of residents sought. EVIDENCE: St Mary`s Residential Care Home DS0000014738.V344892.R01.S.doc Version 5.2 Page 24 On the day we visited the manager Mr D Chadwick was not in the home, however the deputy manager ably assisted us throughout the visit. The statement of purpose records Mr Chadwick’s qualifications and shows that he has the qualifications and experience to be in charge of the home but he has not applied to The Commission to be registered. It is a legal requirement that all care homes have a registered manager, a requirement has now been made that Mr Chadwick applies to the Commission without further delay. A quality assurance system is in operation and results made available; a copy of the latest survey results regarding laundry was on display in the main lounge. Minutes of residents and staff meetings were available and a record of action required and taken. Following requests from residents regarding the suppers, the deputy manager was in the process of changing them to include what residents said they would like. The home does not manage any money belonging to residents but offers to find residents an advocate if they should need help. This is recorded in the statement of purpose. We were told that the policies and procedures in the home are presently being updated by a regional manager to ensure a consistent approach across the company. Certificates seen indicated that the majority of staff had recently attended fire safety training and those that had not were due to have an update in the near future. We were told that safety checks on other equipment is carried out on a regular basis and certificates were available. Risk assessments are carried out for each bedroom and other areas throughout the home. Staff meetings are held and minutes were available. Staff receive training in health and safety and the Inspector observed that all showed an awareness of their role in protecting the residents in their care. Accidents are reported, recorded and audited. Service records for equipment are available. Twelve residents and their relatives completed satisfaction surveys and indicated that they were all happy with the service provided at the home. St Mary`s Residential Care Home DS0000014738.V344892.R01.S.doc Version 5.2 Page 25 St Mary`s Residential Care Home DS0000014738.V344892.R01.S.doc Version 5.2 Page 26 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 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 4 4 4 4 4 4 4 4 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 3 3 3 3 3 3 3 3 St Mary`s Residential Care Home DS0000014738.V344892.R01.S.doc Version 5.2 Page 27 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 OP31 Regulation 8 Requirement The registered provider shall ensure that Mr Chadwick applies to the Commission to be registered in respect of St Mary’s Care Home without delay. Timescale for action 08/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations All residents care records should be available for staff to access on one system. St Mary`s Residential Care Home DS0000014738.V344892.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Residential Care Home DS0000014738.V344892.R01.S.doc Version 5.2 Page 29 - 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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