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Inspection on 02/05/07 for St Mary`s Residential Home

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

This inspection was carried out on 2nd May 2007.

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.

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

The residents do appear cared for and say they are happy with the way the care is offered at St. Mary`s.

What has improved since the last inspection?

Since the last inspection the care plans have been tidied and show clearer details for residents. The Meals have improved and are to improve even further with new menu`s about to be implemented. The Home has a designated Activities Organiser with residents involved and stimulated with a programme of events to interest as many residents as possible. The hot water in nearly all the sinks is now thermostatically controlled. (5 pending. The filing system for all files of residents and staff have greatly improved with any document found easily. All missing personnel records have been sought and all relevant paperwork is now in place. A recommendation that residents have more choice at meal times is actively happening.

What the care home could do better:

The Home needs to continue to develop the recording practise within care plans. The staffing rota`s need to be increased to insure enough staff are on duty at all times. A big effort needs to take place to recruit permanent staff who are qualified to have consistency and skills within the home for the benefit of the residents. The Home must look at the medication procedures and ensure they are robust and managed safely.

CARE HOMES FOR OLDER PEOPLE St Mary`s Residential Home North Walsham Road Crostwick Norwich Norfolk NR12 7BQ Lead Inspector Ruth Hannent Unannounced Inspection 2nd May 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 Home DS0000027467.V338850.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 Home DS0000027467.V338850.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary`s Residential Home Address North Walsham Road Crostwick Norwich Norfolk NR12 7BQ 01603 898277 01603 891105 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) None provided County Healthcare Ltd, a wholly owned subsidiary of Four Seasons Health Care Ltd Manager post vacant Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places St Mary`s Residential Home DS0000027467.V338850.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Forty-four (44) Older People of either sex, not falling into any other category, may be accommodated. 31st January 2007 Date of last inspection Brief Description of the Service: St. Marys is a large single storey building situated in the village of Crostwick.The accommodation consists of thirty-two single and six double bedrooms. Thirty-three bedrooms have an en suite facility. There are a variety of communal areas for the use of service users. St. Marys is situated in its own grounds with a large car park to the front of the premises. Email - st.marys@fshc.co.uk. Fees - £385 - £457 per week. St Mary`s Residential Home DS0000027467.V338850.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report has been completed following a visit to the Home over a 6 hour period by the Link Inspector. The information gathered on the day and further information sent via a pre inspection questionnaire, relatives, residents and medical professionals comments and any further relevant information received at the Commission since the last inspection have been included. The inspection of the medication standard was conducted simultaneously by the Pharmacist Inspector Mr M Andrews. This pharmacy inspection followed five previous visits since August 2006. At the time of the previous pharmacy inspection of 31/01/07 the home’s medication management practices had improved. The findings of this inspection were discussed with Ms D Johnson (Acting Manager) during the visit. During the day a tour of the building took place, residents were spoken to, a meal was taken in the dining room, records were looked at, staff were spoken to and events throughout the day were observed. Overall the Home has started to show sign of improvement in some areas but has a long way to go to ensure all the standards are achieved. What the service does well: What has improved since the last inspection? Since the last inspection the care plans have been tidied and show clearer details for residents. The Meals have improved and are to improve even further with new menu’s about to be implemented. The Home has a designated Activities Organiser with residents involved and stimulated with a programme of events to interest as many residents as possible. The hot water in nearly all the sinks is now thermostatically controlled. (5 pending. St Mary`s Residential Home DS0000027467.V338850.R01.S.doc Version 5.2 Page 6 The filing system for all files of residents and staff have greatly improved with any document found easily. All missing personnel records have been sought and all relevant paperwork is now in place. A recommendation that residents have more choice at meal times is actively happening. 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 Home DS0000027467.V338850.R01.S.doc Version 5.2 Page 7 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 Home DS0000027467.V338850.R01.S.doc Version 5.2 Page 8 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home do now assess fully the potential resident to ensure the Home can meet the persons needs. EVIDENCE: The Home has in place, for the most recently admitted residents, a pre assessment document that has been completed comprehensively by the new Manager. The Manager did admit a resident who had a diagnosis of dementia but was clear that the person had no different needs at this present time than the other residents. The information and care plan was detailed and it was St Mary`s Residential Home DS0000027467.V338850.R01.S.doc Version 5.2 Page 9 clear that this person was suitably placed. The Manager had liaised with the Inspector and managed the situation appropriately. The Manager said she will carry out all pre assessments of residents to ensure all the relevant details are obtained prior to admission. The signature and date of the two most recently completed showed that this is beginning to take place. St Mary`s Residential Home DS0000027467.V338850.R01.S.doc Version 5.2 Page 10 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. Following a period of improvement, the home’s management of medicine practices has again deteriorated. The overall outcome of the medication standard for people using the service is now poor as their health and welfare is no longer as well safeguarded. The standards for the rest of this outcome group has moved forward and the care of residents is improving by more comprehensive, up to date knowledge being written in care plans enabling staff to offer person centred care. However the reviewing of these care plans, especially for those residents who have been at the Home for a while need to be more comprehensive to ensure all areas of care are met fully. EVIDENCE: St Mary`s Residential Home DS0000027467.V338850.R01.S.doc Version 5.2 Page 11 5 care plans were looked at in total during the inspection. Two were for new residents who had a detailed care plan and showed the personal and health care needs of the individual. The old folders have all been replaced and the care plans are divided into labelled sections for easy reading. The most current review had taken place at the end of March with dates and staff signatures in place. The residents who have been at St Mary’s for a longer period of time still have areas within the care plans that are not used. For instance, the weight chart states the person is to be weighed weekly yet no recordings show that this has been happening (last dated 22/02/07 on one and 03/03/07 on another). Also noted was the recording practice of turning bedfast residents with records not in order and sheets of paper loose and disorganised, so although the care plan says it has been reviewed it not so obvious how in depth this is happening. Saying this the overall picture shows a much improved care plan for residents who have been admitted since this Manager was employed. The existing residents need to be updated and reviewed more in depth. -see requirements. The one comment card returned from the GP reflects on the health support offered in the Home as usually good but that some staff need some further skills to help the seamless service aimed for to ensure the health needs are met fully. The District Nurses visit regularly and support the staff to help the residents with dressings, specialist beds and equipment. On the day of the inspection visit an emergency happened when an ambulance was required. The staff handled and behaved in a professional manner throughout the situation. The Pharmacist Inspector conducted an audit of records of medication against medicines available for administration to residents. Whilst for the majority of oral medicines, records of their administration were complete, for medicines prescribed for external application the records were found to be poor with many omissions so it could not be determined if they had been applied in line with prescribed instructions. For one resident, main records indicated that an external medicine (clotrimazole HC cream) prescribed for twice daily application had routinely been made available to the resident for application three times daily. In addition there were found to be neither corresponding records of its administration nor the medicine itself in the resident’s room. For the same resident an ophthalmic medicine prescribed for three times daily administration was being recorded as administered four times daily and so outside the limits of its prescribed instruction –see requirements. The handling of ophthalmic medicines themselves was also raised as a continuing matter of concern. These medicines have a limited life following their time of opening. For some there were no means of determining how long the medicines had been in use –see requirements. St Mary`s Residential Home DS0000027467.V338850.R01.S.doc Version 5.2 Page 12 On auditing Medicine Administration Record (MAR) charts against medicines available for use, it was found that some medicines were duplicated in the medicine trolley in both monitored dosage system (MDS) and ‘original’ containers. This is unsafe and potentially confusing and could lead to medicines being administered from both container types simultaneously. There were often many MAR charts for individual residents with multiple medicine entries of the same medicine, some being completed but not removed. There were some 28-day MDS containers that were not synchronised with other containers or the 28-day MAR charts. This could lead to confusion when selecting medicines for administration-see requirements On conducting sample audit trails, it was frequently difficult to trail and account for medicines. It was concerning to find that frequently staff were annotating ‘carried forward’ figures of medicines as records of medicines received leading to confusion of the audit trails. The inspector found approximately 20 medicine discrepancies in total where they could not be accounted for in full raising concerns that they had not been administered in line with prescribed instructions. Where there were deficit discrepancies, it was of concern that more medicines had been administered than recorded. Where, there were surplus discrepancies, it was of concern that records of medicine administration had been completed by staff but where corresponding medicines had not actually been administered. Ms Johnson confirmed that she was routinely conducting similar audits each week and was also finding discrepancies. A discrepancy of controlled drug Temazepam tablets was also identified in the controlled drug register. –see requirements. It was evident at the time of inspection that there were several medicines that were not available for administration to residents because they had not been re-ordered in time for replacing depleted medicine supplies. For one resident, a water tablet (furosemide) prescribed for cardiovascular use had not been available for administration for a period of four days. For another resident prescribed Stalevo capsules for the management of Parkinson’s disease who was self-administering the medicine, on examination of medicines stored in his room, there were none of this medicine remaining. It was of concern that staff were not aware how long there had been none left –see requirements. For three residents self-administering insulin by injection, there were no risk assessments in place. Ms Johnson confirmed that the ability of each resident to safely handle such medicines had been assessed by community nurses but there were no records of this or knowledge relating to how frequently the residents would be supervised and re-assessed –see requirements. Whilst the medicine storage room is secured when unattended, some medicine storage cabinets within the room were still found to be providing poor security for medicines –see recommendations. St Mary`s Residential Home DS0000027467.V338850.R01.S.doc Version 5.2 Page 13 The staff were observed throughout the day and appeared to offer care and support in an appropriate manner. Conversations were discrete and personal care was offered in privacy. All residents were well dressed in their own clothes with jewellery and lipstick applied if wished. All doors were knocked upon before a staff member entered. St Mary`s Residential Home DS0000027467.V338850.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 good. This judgement has been made using available evidence including a visit to this service. The daily life and social activities has improved to give more quality and choice to the residents to satisfy their social needs. EVIDENCE: The Home has just recruited an Activities Organiser who works 15 hours per week. During the morning residents were having a boules competition and on walking into the lounge it was a pleasure to see residents awake, smiling, conversing and obviously having a good time. (At past inspections most of the residents were asleep in the lounge with only the television on). During the day residents were planning with this staff member future sessions. The recording of whom and in what capacity each resident had participated was held in a file. During lunch another resident talked of how she was going to lead a knitting group with the help of this new staff member. In the small lounge a lady was very actively singing to a CD and some residents were enjoying a conversation in the conservatory. The hairdresser was in the St Mary`s Residential Home DS0000027467.V338850.R01.S.doc Version 5.2 Page 15 building in the afternoon and again conversation and stimulation was taking place. This is much improved since the last inspection. Two visitors were spoken to who have been visiting daily over the past three months. They are very happy with the way they are treated and any questions they may have are answered. There are areas in the Home where people can sit in private and one small lounge has a drink making facility. The new Manager has held relatives meeting, which are recorded (seen), to inform and update anyone involved within the Home. Meals are served either in the dining room or resident’s bedrooms. On the day of the visit the Inspector joined the residents for a meal. There was the choice of steak pudding or chicken casserole with cauliflower, broccoli and carrots. Some residents were having a salad rather than a hot meal and one person was having a jacket potato. The Home have just been sent a copy of new menu’s from Four Seasons that will be implemented shortly (seen) and all the menu’s will be printed in larger format and placed on the tables for residents to discuss and also act as a reminder of what they have ordered. The residents were also offered different types of drink to again offer choice. The whole mealtime has improved and more choice is available. St Mary`s Residential Home DS0000027467.V338850.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives can be reassured that their complaints will be taken seriously and acted upon. Residents are protected from abuse. EVIDENCE: The Manager was actually offered a letter of complaint from a relative who was visiting during the inspection. The content of the letter was shared with the Inspector with the Manager promptly going to the relative and making an appointment to discuss all the concerns. The meeting was held the day after the inspection and a call from the Manager the following day explained that the issues were dealt with very quickly and that the relative was much happier. This Manager does wish to be proactive and resolve concerns as soon as they arise. The complaints procedure is posted in the entrance and the Managers door is nearly always open. Concerns that have been expressed in many comment cards from relatives and residents is the number of staff on duty and the number of agency staff. (See staffing further on in this report). The staff did attend a training on the protection of vulnerable adults last year but some staff are still to have the training, including newly recruited staff. St Mary`s Residential Home DS0000027467.V338850.R01.S.doc Version 5.2 Page 17 These staff members are booked for training with Age Concern, who have been contacted and the Home awaits a date. The staff team have had to deal with a problem recently and the Home handled the situation appropriately with the Inspector kept informed throughout. One comment in a relatives comment card states “I have never made a visit to St Mary’s and seen a resident being abused or roughly handled”. St Mary`s Residential Home DS0000027467.V338850.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home needs to decorate the corridors and replace some flooring to ensure the environment is safe and pleasant. EVIDENCE: A tour of the building took place. The areas identified in previous reports are still in need of improving. The large bathroom flooring is in need of replacing with stained and damaged areas – see requirements and some decoration needs to done to lighten and brighten corridors and bathrooms. The main kitchen has been updated and new equipment and flooring installed which is an improvement. St Mary`s Residential Home DS0000027467.V338850.R01.S.doc Version 5.2 Page 19 The bedrooms seen were clean and tidy and residents had their own possessions around them. All the thermostatic valves have now been replaced except for 5 bedroom sinks that are on order and should be replaced shortly. (Risk assessment in place). Some of the outside area at the front is untidy with weeds and the front drive is still waiting to be renewed (although some effort has been made to fill in some of the bad holes). The Home is now just waiting for the contractors to arrive as the drive is to be replaced. The Inspector, the day after the visit received a fire officers report that states the fire doors are not all suitable in the corridors/hallways. This is a requirement that must be met to ensure all doors are of a fire-resistant standard and be self-closing. – see requirements. The laundry was seen and the staff member spoken to. All the area was clean and tidy. The staff member had attended a COSHH training and all chemicals were appropriately stored. St Mary`s Residential Home DS0000027467.V338850.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing levels need to increase to ensure the correct number of staff meet the needs of the residents. EVIDENCE: The comment cards that have been seen over the past year have all reflected on the staffing levels as poor with also many agency staff being used who do not know the residents. Many staff have left during the period of trying to get management stability for St Mary’s which hopefully will now settle. On looking at the rota’s with the Manager it is evident, due to the size of the building and the number and dependency of residents that the levels of staff are not high enough to meet the needs. The number of residents on the day of the inspection was 35. There were 5 care staff on in the morning that included the Senior and only 4 in the afternoon. This rota needs to be revised and for at least 6 care staff in the morning and 5 in the afternoon. The weekends would be even more difficult for the team as the Manager, Administrator, Handyman and Activities Organiser who all can help throughout are not there, meaning the Senior also has to deal with any emergencies and all callers either visiting or phoning. – see requirement. The number of staff holding a qualification has dropped and a drive to encourage the new staff needs to take place. The Manager had obtained St Mary`s Residential Home DS0000027467.V338850.R01.S.doc Version 5.2 Page 21 information and application forms that were seen on the desk to begin the process of applying. - see recommendation. A big difference has taken place in the organising and updating of the personnel files. Three were chosen at random and neatly contained all the information such as two references, photo ID and birth or marriage certificates. CRB’s were all in place and only one is outstanding and is being followed up. After many problems with these records they are now in order and contain all relevant information ensuring that staff employed are suitable. The Manager has also worked hard to get all relevant courses planned to get all staff updated on their knowledge. In total through May and June a total of 7 courses will be run that include food hygiene, communication and record keeping, diversity, health and safety and moving and handling. During March 2 sessions were held on fire training and a Senior carer is about to go on a ‘train the trainers’ course and then 2 days on a moving and handling training course to then cascade the knowledge to the care staff team. Again this is much improved in the training for staff and all these dates booked were seen in the Managers diary. St Mary`s Residential Home DS0000027467.V338850.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In the short period of time that the Manager has been in post lots of improvements have started to take place. Good leadership with the interests and safety of the residents and staff is evident. However there are still lots of improvements required to bring all areas of responsibility up to a required standard. EVIDENCE: The Manager has just been in post for three months and is beginning to show how the Home can move forward and improve. The Registered Managers Award is to be started on the 15th May. The application for becoming the Registered Manager needs to be completed as soon as possible. St Mary`s Residential Home DS0000027467.V338850.R01.S.doc Version 5.2 Page 23 The Four Seasons company have produced a quality assurance system and they have now all been returned and the result and outcomes for action are yet to be done. This is a move in the right direction to measure the quality of the service The Manager is behind in getting regular supervision sessions with staff on a one to one basis. The Senior staff need to take supervision regularly, especially to aid the quality care required and need guidance/training on how to offer supervision. – see requirement. The home have now purchase a safe that is screwed to the wall and allows access for residents and families to draw out or deposit money with a key that is held by the Senior at all times. The maintenance manual of all the equipment that needs checking on a regular basis such as fire alarms, nurse call bells and emergency lighting has not been carried out for a few months but on the day of the inspection a new maintenance officer was being inducted and all manuals should be completed from now on. –see requirement. Accident forms are in place and held in the Managers office. The completing of regulation 37 forms also takes place with the commission receiving appropriate information on deaths, hospital admissions and significant incidents. The relevant training for health and safety is in hand and the Home has risk assessments to cover potential risk. (The 5 outstanding hot water valves have one). Seen. A new staff member is having the new induction pack produced by Four Seasons and will be assisted by the Senior team. (This staff member only started on the week of the inspection. St Mary`s Residential Home DS0000027467.V338850.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x 2 x x x x 3 STAFFING Standard No Score 27 1 28 1 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x x 2 x 2 St Mary`s Residential Home DS0000027467.V338850.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15.2 Requirement Timescale for action 01/06/07 2 OP9 The care plans must be reviewed with all areas of the care reviewed that include the weight charts and any other care relevant documents. 13.2, 13.4 People who use the service must 01/06/07 have medicines prescribed for external application applied by staff in line with prescribed instructions and this must be demonstrated by record-keeping practices. This is to safeguard people’s health and welfare. – unresolved since the previous pharmacy inspection. 13.2, 13.4 People who use the service must have ophthalmic medicines handled on their behalf by staff safely handled to ensure they are not administered following their expiry times to safeguard people’s health and welfare unresolved since five previous pharmacy inspections. 13.2, 13.4 People who use the service must have medicines administered by DS0000027467.V338850.R01.S.doc 3 OP9 01/06/07 4 OP9 01/06/07 St Mary`s Residential Home Version 5.2 Page 26 staff who have safe systems for medicine administration to safeguard people’s health and welfare. 5 OP9 13.2, 13.4 People who use the service must have oral medicines safely administered by staff in line with prescribed instructions and this must be demonstrated by record-keeping practices. This is to safeguard people’s health and welfare. 12.1, 13.4 People who use the service must have medicines ordered on their behalf by staff in time for their continuous administration to safeguard people’s health and welfare. 14, 13.4 People who use the service and self-administer medicines must have recorded assessments of their suitability to safely handle these medicines and this is evidenced on a regular basis to safeguard their health and welfare. The Home must comply with the fire officers requirements and ensure fire doors as quoted in the fire report of 01/05/07 are purchased. The poor flooring must be replaced in the assisted bathroom. Outstanding requirement. Staffing levels must be increased by at least one staff member on the early and late shift to ensure the needs of the residents are fully met. All staff should have appropriate supervision Records of maintenance, fire DS0000027467.V338850.R01.S.doc 01/06/07 6 OP9 01/06/07 7 OP9 01/06/07 8 OP19 23.4 (a) 01/08/07 9 OP21 23.2 (b) 01/07/07 10 OP27 18.1 (a) 01/06/07 11 12 OP36 OP38 18.2 Sch 4 01/07/07 01/06/07 Page 27 St Mary`s Residential Home Version 5.2 drills and all fire equipment should be in place. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP9 OP28 Good Practice Recommendations It is recommended that steps are taken to improve the security of medicines held in back up storage cabinets. Staff need to be encourage to gain a care qualification as soon as possible. St Mary`s Residential Home DS0000027467.V338850.R01.S.doc Version 5.2 Page 28 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 Home DS0000027467.V338850.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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