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Inspection on 17/04/07 for St Mary`s Residential Care Home

Also see our care home review for St Mary`s Residential Care Home for more information

This inspection was carried out on 17th April 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE St Mary`s Residential Care Home Market Place New Buckenham Norwich Norfolk NR16 2AN Lead Inspector Jenny Rose Key Unannounced 17th April 2007 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 Residential Care Home DS0000061993.V336773.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 DS0000061993.V336773.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary`s Residential Care Home Address Market Place New Buckenham Norwich Norfolk NR16 2AN 01953 860956 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) stmarys1@btconnect.com Jasvinder Paul Singh Banga Jaishree Banga Mrs Daphne Fulcher Care Home 29 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (28) of places St Mary`s Residential Care Home DS0000061993.V336773.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Up to twenty-eight (28) Older People, not falling within any other category may be accommodated. One (1) person, over the age of 65 years with dementia may be accommodated. The total number not to exceed twenty-nine (29). Date of last inspection 20th April 2006 Brief Description of the Service: St. Marys is a large house facing the village green of New Buckenham. Bedrooms are on the ground and first floors and consist of twenty-nine single bedrooms, two of which have an en suite facility. The Home has three communal rooms, a large reception area and a shaft lift is provided to aid service users to the first floor. There is a pleasant dining room with easy access for wheelchair users. Car parking and two enclosed garden areas are to the rear of the premises. A hairdresser visits the home twice a week and chiropody services are available. The Home provides newspapers and toiletries for use by the service users. St Mary`s Residential Care Home DS0000061993.V336773.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care Services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out, by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and the current judgements for each outcome group. The unannounced key inspection took place over 8 and half hours. A preinspection questionnaire had been completed by the manager and returned to the Commission with all relevant details. Three comment cards had been received from residents completed with their relatives. There were no comment cards received from healthcare professionals. There was a late dispatch of all these comment cards by the Commission. During the inspection a tour of the building was carried out and records relating to staff and residents were inspected. Three members of staff were spoken to in private, as well as one visitor. Several residents were spoken to in passing and three in private. The information from the comment cards and from the people spoken to has been incorporated in the report. Overall, the information received prior to the inspection and the evidence observed and inspected on the day of the inspection suggested that St Mary’s House is a good service offering good quality care. However, the adoption of a more robust quality assurance system of recording and auditing would ensure a better, holistic service. What the service does well: • The historic building with its two enclosed garden areas are situated at the centre of the village facing on to the village green area offering a pleasant view for residents. There is a good staff team and residents and relatives speak highly of the care delivered. There are monthly residents’ meetings, regular staff meetings, as well as questionnaires, in order to develop new ideas. Residents’ choices in food and special diets form the basis of traditional, home style cooking and meals preparation. • • • St Mary`s Residential Care Home DS0000061993.V336773.R01.S.doc Version 5.2 Page 6 • • • • An activities programme, based on residents’ wishes has been developed. The management shows a commitment to staff training and development across the whole of the staff team. Relatives and friends are welcomed into the home at any time and residents supported to maintain their links with the community. As a result of a residents’ questionnaire, a tuck shop has been set up with items specifically requested by residents. What has improved since the last inspection? • Refurbishment of carpets, bathroom flooring, curtains, new kitchen, cleaning and office equipment and redecoration has taken place in various areas. An adjoining cottage has been purchased and is used as a staff training area as well as private meeting space for residents and relatives, or staff. The care plans showed improvement and all care staff have received training in writing care plans involving residents and/or relatives. There is a system for reviewing and improving care, but there is still some room for improvement. Recruitment procedures have improved and the necessary documents are on file. All new staff receive supervised and induction training is recorded. Residents’ needs are assessed before admission and this only take place if the Home can meet the assessed needs of the prospective resident. There are Job Descriptions for the Registered Manager and the new Deputy Manager. There are photographs of management and keyworkers in the front entrance hall, indicating who is on duty throughout the day. Further attention is being given to the nutritional needs of residents by the attendance of the cook on a training course in Nutrition, information from which, she will cascade to the rest of the staff team. The Home seeks advice from Healthcare Professionals whenever appropriate DS0000061993.V336773.R01.S.doc Version 5.2 Page 7 • • • • • • • • St Mary`s Residential Care Home What they could do better: • • • A robust quality assurance system of recording and auditing would further ensure a more holistic service and continuous improvement. There is room for improvement for management reviews, spot checks and auditing of care plans. There is room for improvement in the recording of the life histories and interests and hobbies of residents, some of whom may not attend residents’ meetings, to ensure that the wishes of all the residents are reflected in the activities programme. Support should continue to be given to those members whose first language is not English in improving their communication skills, both verbal and written in order to ensure the needs of residents are being met. It is recommended that new Deputy Manager should be given the opportunity for training in IT skills for her better to fulfil her role as support to the Manager. • • 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 DS0000061993.V336773.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 DS0000061993.V336773.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 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Pre-admission assessments are made prior to a resident’s admission so that people can be sure that their needs can be met in the Home and care plans are formulated from these. The home does not offer intermediate care. EVIDENCE: The comment cards suggested that residents and their relatives had received sufficient information on which to make their decisions before admission. On the day, a visitor was looking round the Home on behalf of her relative, whom she intended to bring to visit the next day to help her make a decision. Two care plans examined showed that pre-assessments gave detailed information of residents’ needs upon which care plans could be based, together with information from other healthcare professionals. A frequent visitor spoken to said that her relative had chosen to come to the Home, as he knew it well in the past, and that he had come for a trial period before deciding on a St Mary`s Residential Care Home DS0000061993.V336773.R01.S.doc Version 5.2 Page 10 permanent stay and they were both very pleased with the care he was receiving. The Manager said that the new technology in the office was helpful in obtaining information, especially from healthcare professionals before admission. She also said that new brochures would soon be available, which would give clearer information to prospective residents. St Mary`s Residential Care Home DS0000061993.V336773.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 good. This judgement has been made using available evidence including a visit to this service. People in the Home have their healthcare needs monitored and appropriate action taken when these change, according to individual choices and are protected by the policies and procedures surrounding the administration of medication. EVIDENCE: Four residents were spoken to and their care plans were examined which indicated that there had been improvements in the care plans. Care staff have recently undertaken a Care Planning and Recording course as a result of the last inspection. There was one particularly good care plan containing a photo, good details of a life history, the choice of the resident for female carers, long term needs assessment, activity chart and various areas of her care regarding moving and handling, personal hygiene, continence regularly reviewed and signed by the resident. This care plan had been audited, as an informal spot check by the Manager. Also a comment card stated, “When new care plans are put in place all members of staff are informed.” St Mary`s Residential Care Home DS0000061993.V336773.R01.S.doc Version 5.2 Page 12 There were risk assessments for falls, particularly in one care plan. The comments in one comment card from a relative said,”When new care plans are put in place, all members of staff are informed.” And “My relative now has a care plan that is very specific to her and it is carried out well”. However, there was not consistent quality in the recording in the care plans, although it was evident from discussions with staff that they were well aware of the residents’ needs. Two care plans contained no photograph, which the Manager explained would be rectified when the digital camera was next in operation and were not signed by the residents or their relatives, although a visitor spoken to said that she had been involved in her relative’s care plan and had been kept informed on two occasions recently regarding changes in her relative’s health and of the steps the Home had taken on his behalf. There is therefore a requirement that care plans should be regularly audited as part of a more robust quality assurance system (see Standard 33) to further ensure a consistent quality of delivery of care. There was evidence that healthcare professionals were involved where necessary and advice sought. The Manager said that the Home have a designated District Nurse, who was regularly available to give advice and in particular helping staff to monitor the care of pressure areas and gave ‘on the job training’ to the care staff. One resident was of the opinion that he owed the great improvement to his health to the care given to him in the Home. It was observed during the day that staff treated residents respectfully and with humour, if appropriate. One resident said, “Staff treat me with dignity. I wouldn’t want to have a key to my room, but I could have one if I wanted”. The medication round at lunchtime was observed. The new Deputy Manager was administering the medication appropriately. She has several years experience and has completed Medication Training, as have the four senior staff and two care assistants who also administer medication. The storage and recording of Controlled Drugs appeared to be satisfactory. There was continual evidence of the auditing of medication and the MAR sheets completed satisfactorily. No one in the Home was self-medicating, but a newly admitted resident for respite care said that she preferred that the staff administered her medication for the time being. St Mary`s Residential Care Home DS0000061993.V336773.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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 in the Home have opportunities to choose their meals, how to spend their time, with flexible routines, activities and to continue to maintain relationships with family, friends and the community. EVIDENCE: There are flexible routines as far as possible within the home in order to accommodate residents’ choices in the timing of breakfast, for example. One resident was observed having her breakfast later in the morning, which was her choice. Where possible, residents were also able to choose the décor in their bedrooms. Evidence from comment cards, discussion with the manager, staff, residents, relatives, minutes of the most recent residents’ meeting and the activities programme seen, confirmed that there is a monthly programme of events in house, as well as outings on a group basis. Activities, such as a Beetle Drive and arrangements for an outing made at a previous residents’ meeting were seen to be carried through in the programme. The comment cards and discussions with staff, a relative and residents demonstrated that relatives are welcomed at any time to the home. In addition, some residents are well enough to go out with their relatives/friends, St Mary`s Residential Care Home DS0000061993.V336773.R01.S.doc Version 5.2 Page 14 to attend Church, or the Vicar brings Communion to the Home. One resident is pleased to be able to attend the Common Meeting and the local Good Companions Club invites three residents and one carer to attend their meetings. There is a communal local paper and any other papers/magazines are available from the nearby shop. Although activities are recorded on a tick box basis in the care plan, a recommendation is made that activities are more fully recorded in the care plan in the same section as individual interests and hobbies, although in many instances these are already well known to the staff, in order to ensure that peoples’ needs in this area are being met. The comment cards demonstrated that relatives are welcomed at any time and and contacted in between if necessary. One visitor spoken to said that she visits on a regular basis and had recently completed a questionnaire regarding the Home. The Comment cards, residents spoken to, relatives and staff agreed that, “The food is very good”. The menu was advertised for the day and there have been questionnaires for two years running on choices for meals and the menu adapted accordingly and residents choose their options each day. The Tuck Shop was as a direct result of a suggestion in the last questionnaire concerning the meals in the Home. The cook, who has catering qualifications and many years experience was observed speaking to all the residents following lunch asking for comments, suggestions, or complaints. The cook said that the Home recognises the importance of nutritious meals for the health of the residents and that special diets, such as diabetic or liquidised diets were catered for. She has undertaken a course in Reminiscence and tries to incorporate homecooking into the delivery of meals. Traditional meals, such as Bubble and Squeak appeared on the menu. The cook is about to undertake a course in Nutrition, information from which she will be cascading to the staff team. The menus and the meal seen on the day offer choice of wholesome, nutritious food prepared largely from fresh ingredients. Weight charts monitor residents’ nutritional needs in the care plans. The Home has recently been awarded the Gold Award for Food Hygiene, which the Manager said was the result of the staff team’s effort Residents were able to choose to take their meals where they felt comfortable. There was a pleasant dining area, with attractively presented tables, but one resident said she preferred to take her meals sitting quietly in her place in the entrance hall. Residents who required assistance with eating were seen to be helped in a discreet and sympathetic manner and meals were served in residents’ rooms if appropriate. St Mary`s Residential Care Home DS0000061993.V336773.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives feel their concerns are listened to and are protected by the policies, procedures and staff training in the Home. EVIDENCE: All the comment cards and the residents spoken to felt they knew how to make a complaint or express a concern if they needed to. They felt that the staff always listened to them and took action if necessary. One resident said he would know how to make a complaint, but he did not have any. A relative who visits every week said, “Staff are lovely and I haven’t had to make a complaint” and she added that from her own working experience she would know how to do this if necessary. In order to facilitate communications with staff of any concerns, photographs of the staff on duty during the shifts are displayed in the entrance hall. All the staff spoken to gave a good account of the procedures to be followed should there be any issues regarding the protection of vulnerable adults and there was evidence that all staff had received training in this and that the necessary recruitment checks were in place. St Mary`s Residential Care Home DS0000061993.V336773.R01.S.doc Version 5.2 Page 16 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 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home provides a safe, comfortable and clean environment for the people who live there and there are continuing improvements being made. EVIDENCE: This is an old building at the centre of the village, with a shop and two pubs. There are two enclosed gardens, accessible to residents, which are maintained by the part time maintenance person. The Home has three communal areas and with the recent acquisition of an adjoining cottage, there are facilities for private meetings, for use by residents and their relatives, or staff, hairdressing facilities and a staff training area with computer/video equipment. A privacy screen is available for use by Community Nurses, if necessary, in the communal areas. A number of improvements have taken place since the last inspection; refurbishment of carpets, flooring in two bathrooms, curtains, new items of St Mary`s Residential Care Home DS0000061993.V336773.R01.S.doc Version 5.2 Page 17 kitchen, cleaning and office equipment and redecoration in various areas. There was scuffed paintwork near to the lift, but the manager explained this would be part of the making good process following the installation of a new lift in July 2007. For security purposes, there has been a new front door entry system installed, following a requirement at the last Inspection, as well as a new telephone system. All bedrooms seen were personalised and comfortable and one resident said he was particularly pleased with his room, comfortable bed and having being adjacent to a toilet. In one vacated room, redecoration and refurbishment would be put in hand according to the new occupant’s wishes. There are only two bedrooms with ensuite facilities, which are part of a longer term development plan. One comment card remarked that there was no easy wheelchair access at the front of the building, but the Manager pointed out that this was possible at the rear of the building. During a tour of the building, all areas seen were clean and tidy and there have been improvements in the laundry area and there is a washing machine solely for kitchen laundry, which is part of the Home’s procedures for Infection Control. St Mary`s Residential Care Home DS0000061993.V336773.R01.S.doc Version 5.2 Page 18 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. The people living in the home have confidence in the staff who care for them, but a review of the keyworkers’ role would further ensure that the service is resident focussed. EVIDENCE: There is evidence from staff rotas that the Home is adequately staffed and the Management keep control of the staff rota to ensure the skill mix of staff. The staff spoken to were enthusiastic about their work. The staff files demonstrated that the necessary recruitment documents, including two references and current Criminal Records Bureau checks are in place. There is a management commitment to training and the purchase of the adjoining cottage provides a separate, private area for staff training with the necessary training aids for training in house. At least 53 of staff have NVQ level 2 or 3. New members of staff undertake Induction Training. As a result of the previous inspection, there has been training for care staff in care planning and record writing, Dementia Awareness, amongst others, and St Mary`s Residential Care Home DS0000061993.V336773.R01.S.doc Version 5.2 Page 19 ongoing English lessons for those members of staff whose first language is not English. The cook has Catering Qualifications, but has also undertaken a Reminiscence Course, is the Home’s First Aider, and is about to undertake a course in Nutrition, information from which it is intended to cascade to the staff team. The Manager is undertaking a course in Equality and Diversity with the new Deputy Manager, who is about to undertake the NVQ level 4 in Management. The three comment cards, the visitor and residents spoken to were all positive regarding the staff team, but one in particular stated that “St Mary’s has a very caring staff from the manager through to cleaners and kitchen staff. They know the requirements of each resident and treat them with care and affection.. Although St Mary’s is not the most modern establishment, it more than makes up for this in the dedication and attention of the staff.” However, there is a recommendation that the keyworkers’ role should be reviewed with the staff concerned; particularly following the training in care planning and recording and the appointment of a new Deputy Manager; in order for the life histories and particular interests and hobbies of those residents, whose views are not known through residents’ meetings, to be taken into account in planning any activities programme. St Mary`s Residential Care Home DS0000061993.V336773.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home has a clear management structure and the interests of the people living in the Home are taken into account in the running of the Home. However, a more robust quality assurance system of recording and auditing, would ensure a better holistic service. EVIDENCE: The Manager has many years experience of the care of older people and has the NVQ level 4 in Management. She has continuously pursued the updating of her own knowledge, not only in care issues, such as Risk Assessments, Health and Safety, but also in the training and development of staff and managing complaints. She is shortly to attend a course, with the very recently appointed Deputy Manager, on Diversity. She shows clear leadership to the staff team and has the backing of the Proprietor in this role. The Proprietor visits the Home every week, takes part in some staff meetings and writes St Mary`s Residential Care Home DS0000061993.V336773.R01.S.doc Version 5.2 Page 21 regular Regulation 26 reports on a monthly basis stating how well the home is running. Since the last inspection there has been an updating of the office area and facilities, such as a new computer system. The Deputy Manager appointed shortly after the last inspection has opted to return to her care assistant role and a new Deputy Manager has very recently been appointed. She has several years experience working in the Home and as a Senior Carer, she is enthusiastic about her new role in supporting the Manager, and is about to undertake her NVQ level 4 in Management. There are job descriptions for both the Manager and Deputy Manager, which give a clearer structure to the management of the Home. This was a recommendation from the previous inspection. The Manager is beginning to delegate tasks such as the staff rota, which is well controlled to ensure that the Home is satisfactorily staffed with the relevant numbers and skill mix of staff. There is a recommendation for IT training for the Deputy Manager in her supportive role to the Manager. There are considerable improvements to the variety of measures to monitor quality in the home to ensure it is run in the the best interests of all the residents. These take the form of regular residents’ and staff meetings, questionnaires regarding the meals, as well as residents’ views being sought day to day by the cook and other members of staff (see Daily Living). Clearly, there are activities, taking into account residents’ individual interests, (see Activities) and the Manager has produced a report of the Quality of Care. However, there is a requirement for a more robust system for quality monitoring to include spot checks, which are already being carried out being formally recorded, and an auditing system established, particularly in the area of care planning records, which ensures that views of residents, relatives, healthcare professionals and staff are taken into account in the deliver of the service. The Home does not handle residents’ money and ensures that those residents who do not have family or friends to support them, are put in touch with a solicitor or advocate, if appropriate. Records demonstrated that health and safety issues are regularly reviewed and updated and there have been recent Health and Safety Risk Assessments and Fire Risk Assessments on the building by professional agencies and the manager ensures that all staff are aware of the policies and are trained to put theory into practice and are appropriately supervised. St Mary`s Residential Care Home DS0000061993.V336773.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 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 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 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 3 X 2 X 3 X X 3 St Mary`s Residential Care Home DS0000061993.V336773.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP33 Regulation 24 (1) (a) (b) Timescale for action The present system for reviewing 20/09/07 and improving care must be made more robust, particularly in the recording and auditing of care plans to ensure people living in the home receive a more holistic service Requirement 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 OP12 Good Practice Recommendations The way in which the service records the interests and the hobbies of the people living in the home should be linked with the activities programme in order to ensure that all residents’ needs in this area are being met. The keyworkers’ role in gathering information regarding life histories and particular interests and hobbies of the people living in the Home should be reviewed, in order to ensure the life style in the Home meets their needs. 2. OP30 St Mary`s Residential Care Home DS0000061993.V336773.R01.S.doc Version 5.2 Page 24 3. 4. OP30 OP30 The Deputy Manager should be offered the opportunity for IT training in order to better fulfil her supportive role to the Manager The support of staff for whom English is not a first language in improving their verbal and written skills in English should continue in order to provide better communication with those people living in the Home. St Mary`s Residential Care Home DS0000061993.V336773.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 DS0000061993.V336773.R01.S.doc Version 5.2 Page 26 - 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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