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Inspection on 31/01/07 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 31st January 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 Home has a core of staff who are suitable and care for the residents in an appropriate manner. These staff do get to know the residents and offer the care as required.

What has improved since the last inspection?

The Home has a refurbished kitchen, which has greatly improved the facility. There is a sluice in place that should improve the cleanliness within the Home. Some staff training has taken place. Some carpets have been replaced and some rooms have been repainted. There has been some improvement in the medication procedures.The corridors have now had new lighting installed, which has improved the brightness in the communal areas. The Home has recruited a designated Activities Organiser, which ensures some parts of the week days an activity is taking place.

What the care home could do better:

The Home have on numerous occasions, been required to improve the care plans that are held for each resident and although the formats have changed the writing of information has seen little improvement and gives limited information about the individual resident. The Home needs to ensure a comprehensive assessment of care needs is carried out. The staff team need to be more aware of infection control procedures and ensure that their work practice reflects this. The team of staff need to be sufficient in numbers at all times to ensure continuity of care at suitable times is available. To offer continuity and leadership the home needs to have a Manager in post who can move this Home forward by assessing, putting into action and reviewing the care service offered.

CARE HOMES FOR OLDER PEOPLE St Mary`s Residential Home North Walsham Road Crostwick Norwich Norfolk NR12 7BQ Lead Inspector Ruth Hannent Key Unannounced 31st January 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 Home DS0000027467.V329520.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.V329520.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 Position 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.V329520.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. 9th June 2006 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 - £435 per week. St Mary`s Residential Home DS0000027467.V329520.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection Report is written following a Key unannounced inspection. Over the past year the Home has also received random inspections that are mentioned in this report. The Inspector was accompanied by the Pharmacist Inspector who has also been carrying out random inspections of the Home over the past twelve months looking at specific concerns around safe management and administration of medication. The day was assisted by, the new Manager who has been in post for only two weeks. The leaving manager was also available, as was three staff members and four residents. The Commission had received 8 residents comment cards and 8 relatives comment cards. The Comments are mostly favourable and speak well of the staff and Manager with some concerns raised about the number of staff required to carry out the care in suitable times for residents. Throughout the day five residents, three staff and two visitors were spoken to. Records seen included care plans, personnel files, staff training, rota’s, servicing records and finance details. A tour of the building took place and a meal was taken with the residents in the dining room. What the service does well: What has improved since the last inspection? The Home has a refurbished kitchen, which has greatly improved the facility. There is a sluice in place that should improve the cleanliness within the Home. Some staff training has taken place. Some carpets have been replaced and some rooms have been repainted. There has been some improvement in the medication procedures. St Mary`s Residential Home DS0000027467.V329520.R01.S.doc Version 5.2 Page 6 The corridors have now had new lighting installed, which has improved the brightness in the communal areas. The Home has recruited a designated Activities Organiser, which ensures some parts of the week days an activity is taking place. 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.V329520.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.V329520.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 and 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A full assessment of needs is not always in place prior to admission of a resident. A potential resident and family may not always be aware if the Home can meet the needs if a full assessment has not taken place. EVIDENCE: The Home has assessment forms which are standard documents used in all Four Seasons Homes that are appropriate to assess the needs of the individual person and ensure the service provided can be met. To make sure these forms can be completed comprehensively information from all relevant professionals needs to in place on writing these assessments, which unfortunately has not happened recently. Due to the lack of information obtained a resident has St Mary`s Residential Home DS0000027467.V329520.R01.S.doc Version 5.2 Page 9 been in the Home for over a week who has a diagnosis that puts them outside the registration category of the Home. It was not until the person was already in the Home that the correct paperwork was received giving a comprehensive description of the person and the diagnosis, making the placement inappropriate. No one should be admitted to the home until all details are received (Requirement). This unfortunately means that the Home has not the correct level of staff, relevant staff training or the correct environment that is required to meet the needs of this person. With what is now an incorrectly placed person whose needs may not be met appropriately and may have to go through another move to find a suitable Home. Residents who have been at the Home for a period of time appear appropriately placed in St Mary’s and do say they are having their needs met. St Mary`s Residential Home DS0000027467.V329520.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 poor. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs are not always set written in the residents care plan. Resident’s health care needs are met. The Home still has some improvements to carry out to ensure all medication procedures are safe and adhered to by all staff who handle medication. Residents are treated with respect and their privacy is upheld. EVIDENCE: In total five care plans were looked at in detail. The Four Seasons Company has formats that are now in each care plan but information in these care plans are very minimal. The residents all have key workers allocated and are responsible for building the information in these care plans to enable staff to St Mary`s Residential Home DS0000027467.V329520.R01.S.doc Version 5.2 Page 11 have a comprehensive picture of the needs of each resident. This was not evident with minimal information being recorded. Many of the required documents were not written on and of four of the care plans the Inspector could not gather any information about the person. No history, no social interests, irregular information such as when residents are weighed and very limited information in the daily progress sheets. Comment such as ‘up washed and had breakfast’ or ‘slept well’ is the kind of progress reports written. There was no information for example on how the person had spent the day, had they received visitors, how was their appetite, or someone not so well and for staff to monitor. Care plans have been an issue for this Home over the past eighteen months with the requirement not being met on three past inspections and although new formats have been introduced the standard of written detail does not meet the minimum standards required and is once again a requirement that needs immediate action to prevent enforcement action by the Commission taking place. (Outstanding Requirement x 4) The Home has regular contact with the GP surgery and the Community Nurses visit regularly. There has been no comments received at the Commission from health professionals but five residents spoken to felt their health care needs are met and one written comment from a resident spoke highly of the support she had received for her complex needs. It was noted that a resident being cared for in bed was being monitored for pressure areas with turning charts in place. The records could be improved by ensuring that when a document is full, a new form is in place so that the information is not crammed on the bottom of the page making it difficult to read. The chiropodist visits monthly and via referrals a specialist can be called in such as a speech therapist or physiotherapist. On the day of the site visit a comprehensive inspection of the medication was undertaken by the Pharmacist Inspector over a period of three hours with a detailed report held at the Commission. This follows random inspections that have taken place over the past year with the result that most of the requirements have been met or have improved since the last inspection. Some more concerns that had not been inspected in the past have meant three new requirements are now in place. (3 Requirements). Throughout the day the conversation heard and the manner in which the staff were going about their duties was noted as respectful and courteous. Doors were knocked on before a staff member entered. Conversations such as would you like this item or that item to wear showed choice and polite chat while duties that were taken place were suitable and behind closed doors to preserve dignity. . St Mary`s Residential Home DS0000027467.V329520.R01.S.doc Version 5.2 Page 12 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. Resident’s interests are now being included in daily activities on a part time basis. Resident’s families and friends visit whenever they wish. Resident’s are helped to make choices and take control over their lives. Resident’s do receive a wholesome meal but more choice in quantity size or improving the surroundings would make an improvement. EVIDENCE: The atmosphere on walking the building appears improved with residents smiling and talking about the activities that are now available within the Home. (Noted was the weeks activities programme on the notice board by the dining room). From comment cards received many residents talk positively about the planned events but on the day of the site visit the Activities staff member was St Mary`s Residential Home DS0000027467.V329520.R01.S.doc Version 5.2 Page 13 not working and it was noted how residents were sitting in the large circle in the lounge with nothing to stimulate them other than the television at the far side of the room that was not being watched. Records of who takes part in which activities is now kept by the Home, which shows quite a number do get involved. What does not happen is forms of stimulation at all times of the day. No staff member was in that lounge at any part of the inspection other than to take a drink or assist someone to the toilet or dining room. No interaction was happening and some residents were asleep. Although the Home has improved over the year by employing a part time activities staff member more thought needs to go into the days when nothing is planned and even if residents do not wish to join in, the availability is there for them to choose. (Recommendation). Comment cards from families stated they are made to feel welcome and during the visit to the Home two family members were spoken to. Both felt they were made welcome. One family member visiting daily at present, to help the resident settle in, was offered tea and felt comfortable throughout the visits. Residents are offered choice. One gentleman prefers to manage some of his medication and has a system that suits this. (Discussed) Resident’s rooms are personalised and the Home will help them make it as suitable as possible. All residents have their care plans in their own rooms and are able to access them whenever they wish. A meal was taken in the dining room with some of the residents. Comments written and information gathered on the day state that generally the food is not bad but some would like a wider variety of fresh vegetables or for tea brown bread as well as white. The choice on the day of the visit was pork chops or sausages with broccoli, mixed vegetables and mash. The meal was all served up on the plate according to choice. The amount on the plate or the choice of which vegetables are preferred was not available. Although the meal was enjoyed on being asked, it was noted on comment cards that sizes of appetites is not taken into account and what and how much available is not taken in to account as everything is plated in the kitchen. (Recommendation). The dining room is still upside down since the refurbishment of the kitchen and needs a face lift with matching furniture and tablecloths/napkins that are not creased to make the meal more enjoyable. St Mary`s Residential Home DS0000027467.V329520.R01.S.doc Version 5.2 Page 14 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. Resident’s and relatives can feel confident that their complaints/concerns will be listened to and acted upon. Resident’s are protected from abuse. EVIDENCE: The Home has a complaints procedure that is the standard one written by Four Seasons. The Manager who has only been in post since the beginning of the month had received a complaint and has acknowledge the letter by writing to the complainant stating an investigation would take place and the timescale in which the person would be notified of the outcome. (Seen). The Manager has also arranged for the specialist who will help resolve the problem to the Home on the coming Monday. Comments on the cards received at the Commission said they would ‘go to the top’ or ‘speak to the Manager’ and have had any concerns in the past dealt with. The Home has, over the past year, held training sessions for all staff on the ‘protection of vulnerable adults. The Home has also informed the Commission this month of the possibility of some money going missing. The Home have reacted appropriately and called the police who have been in to see the St Mary`s Residential Home DS0000027467.V329520.R01.S.doc Version 5.2 Page 15 resident and have discussed the situation with a report to follow shortly. One staff member spoken to would have no concerns about reporting any potential abuse to the Manager and feels confident that it would be dealt with appropriately. St Mary`s Residential Home DS0000027467.V329520.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): 19,21,25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents do live in an environment that is well maintained but some records to prove the safety needs to be available. The bathroom facilities are in need of repair and could be more pleasant. Residents do not always have safe surroundings. Some parts of the Home are not pleasant and hygienic. EVIDENCE: On walking the building it was noted that the Home is well furnished although some of the rooms have odd pieces of furniture that do no match. The carpet St Mary`s Residential Home DS0000027467.V329520.R01.S.doc Version 5.2 Page 17 in the main entrance is looking stained and some bedrooms have an odour, especially the small bedroom by the front door. The Home has recently undergone a refurbishment in the main kitchen, which has improved the area greatly. The Environmental Officer inspected recently and is to do a return visit now the kitchen is completed. (Letter seen). The recent fire report, which was compiled after a recent fire at the home shows all areas are now compliant (A requirement was to replace faulty emergency lights which has now been done). The Regional Estates Manager has also carried out a fire risk assessment (seen) for the whole building and regular alarm checks and fire drills at regular intervals are recorded (seen) with the staff who attended, named. Some service records could not be found to ensure all equipment was safe. The Home has enough assisted bathrooms but some are in poor repair. The flooring in the bathroom with the large bath is lifting and has a hoist that is broken in the corner. Two of these rooms were dirty and untidy. Dirty underclothing was in one bathroom and in the hairdressing/bathroom unsafe items were stored such as electric extension cables. (These were immediately removed). One bedroom had a soiled dressing on the carpet and used, disposable gloves were left lying around. (Requirement) The Home had a requirement to ensure all the taps that were accessed by residents had a thermostat valve in place and these are now on order and are to be installed the week beginning the 5thFebruary. (Action date received at the Commission from the Regional Manager). The water to resident’s basins is still too hot and the basin used by the hairdresser has a rubber shower hose, which is difficult to control when washing hair. (No risk assessment in place). (Requirement) Since the last Key Inspection the Home has installed more suitable lighting for the corridors where their was no natural light and now makes the area much brighter. The Home has just purchased a sluice with a machine that can sterilise all bottles, commode pans etc. This should assist greatly in infection control as long as staff follow clear guidance by remember their training and not leave soiled, dirty items around. The laundry has two washing machines one with a clear sluice cycle and one new tumble dryer. The safety data sheet for all cleaning chemicals, are in a folder within the store cupboard and do match the chemicals held on the store cupboard shelves. (Seen) St Mary`s Residential Home DS0000027467.V329520.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 27, 28, 29 and 30 Resident’s needs are met but not always when required. The Home needs to find some stability in the staff team and help them attain a qualification. Resident’s are protected by the Home recruitment procedures. Staff do have training but more consistency is required. EVIDENCE: Nearly all comment cards reflected on the staff, although good, appeared to be busy especially mornings and evenings and one comment was “if the call bell rings it can take quite a while to be answered sometimes 20 to 30 minutes”. It was noted on the day of the inspection the buzzer ringing fairly regularly but these were answered within a few minutes. 35 residents were residing on the day of the visit and the rota showed enough people in the building to ensure the care was being delivered at appropriate times. The comment cards seen were from families who possibly visit at weekends when less staff are in the building. With the Manager and administrator off duty, phone calls or greeting visitors has to be dealt with by the people on care duties and this can mean more to do with less staff on duty. (Recommendation). The residents St Mary`s Residential Home DS0000027467.V329520.R01.S.doc Version 5.2 Page 19 spoken to appeared happy with the care and felt the staff were good who helped them but all nine comment cards had ticked that staff only sometimes were available to help them when needed. The Home has had quite a large staff turnover in the past year and consistency of staff is a concern. Along with this is the concern of getting 50 of staff with an NVQ qualification and although in the past the number of qualified staff was fairly good this has again altered with the staff turnover. (Requirement) The personnel files of recently recruited staff are all complete with documents checked on three new staff. Concern was shared with the Manager of some records missing in personnel files of long term staff. A list has been drawn up my the new Manager (seen) and records that can be obtained will be done so straight away. (Recommendation) The New Manager is to spend some time on the training records of staff to build a matrix of which staff have covered which training and when that training is due for renewal. Copies of who has attended what training is held on file and staff are slowly getting the training that requires them to carry out their job safely and correctly. A suggestion would be that training on the writing of care plans takes a high priority in the planning of staff training. (Recommendation) On talking to two staff members, training could be improved to ensure the skills are kept up to date with some staff “not up to date with moving and handling and more help in the understanding of dementia is asked for by the staff team”. St Mary`s Residential Home DS0000027467.V329520.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): 31,33,35 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. This new Manager appears competent but is still very new to make a judgement. The Home still needs a system to ensure the best interests for residents is in place. Resident’s finances are safeguarded. The protection of health, safety and welfare of resident’s and staff is not always evident. EVIDENCE: St Mary`s Residential Home DS0000027467.V329520.R01.S.doc Version 5.2 Page 21 The Home has recently recruited a new Manager (January 2007) with the residents having four Managers (one being a relief Manager) over the past year. This has not helped in the leadership and direction of the Home with so many changes. The new manager has experience within the care sector and on the day of the site visit gave a good indication of the skills required to be a good Manager. Two staff members both stated they felt already that a good Manager had been appointed and “at last things will get done properly”. The Inspector was informed that this new manager is to undergo a three months probation period prior to becoming registered. At present the home has no clear quality assurance procedure. The Company of Four Seasons Healthcare are, according to the recently returned action plan received at the Commission, issuing questionnaires to all residents, relatives and friends to assess the service provided. (A date for when this is to happen was not given) To date no systematic cycle of planning, action and then review has taken place to check and improve the quality of the service. This has been an outstanding requirement over the past twelve months and is still not implemented. (Outstanding requirement x 4) The resident’s money is held in a safe within the office. The Home has clear receipts for transactions that take place for the resident. The main area of concern is how residents have access to their own money when the main office is locked at the weekends. If families wish to leave money for their relative or a resident wishes to use their money nothing can be done until the Monday when the Management or Administrator are in the building. A more suitable management of money that is still safe needs to be in place at weekends or bank holidays to ensure access to residents own money is available at all times. (Recommendation). The Home needs to deal with issues such as infection control as this visit showed, as mentioned in the environment standards, dirty items, used dressing and used disposable gloves lying around. The training in this area needs to be in place and checks on infection control standards needs to be implemented. As mentioned by staff some moving and handling training is overdue to ensure correct and safe methods are used. The cleaning cupboard does have all safety data sheets in a file that match the chemicals on the shelf, which is easily accessible for staff. On the day of the inspection this cupboard had been left unlocked and contained many different cleaning materials. The domestic staff member was nowhere in sight and residents were walking the corridors. (Requirement). Regulation 37 notifications of events have been forwarded to the Commission with the most recent received of possible missing money. The Home acted appropriately and called in the police and the resident was interviewed. The St Mary`s Residential Home DS0000027467.V329520.R01.S.doc Version 5.2 Page 22 Home is keeping the Inspector up to date with this concern, which is being handled appropriately and professionally. The new Manager has spent some time in the two weeks of appointment trying to find clear servicing records of all equipment within the building. The only record found of the servicing of the boiler was a piece of card in the boiler room with dates on it. Some records were seen of water checks and hoisting equipment but with no other receipts or service records available it was difficult to ascertain what had or had not received a regular service. (Requirement) St Mary`s Residential Home DS0000027467.V329520.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 2 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x 2 x x x 2 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 1 x 2 x x 2 St Mary`s Residential Home DS0000027467.V329520.R01.S.doc Version 5.2 Page 24 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 OP3 Regulation 14 a,b,c Requirement The Manager must ensure a full assessment of the potential resident takes place before a placement is offered to ensure the care required is within the registration of the Home. The Manager must ensure all care plans are detailed to include health, personal and social care needs. Outstanding requirement x 4 The registered person must take steps to ensure medicines prescribed for external application are stored securely when not in use. The registered person must take steps to ensure medicines of limited life on opening are safely handled to ensure they are not used following their expiry times -Unresolved since previous four inspections The registered person must take DS0000027467.V329520.R01.S.doc Timescale for action 01/02/07 2 OP7 15.1 01/03/07 3 OP9 13.2, 13.4 16/02/07 4 OP9 13.2, 13.4 16/02/07 5 OP9 13.2, 16/02/07 Page 25 St Mary`s Residential Home Version 5.2 13.4, 17.1 – sched 3 6 OP25 13.4 a 13.4 c steps to ensure the administration of prescribed external medicines is fully, and accurately recorded. The Manager must ensure that risk assessments are in place to cover safety while a problem is rectified such as water temperature valves. The Manager must ensure that all areas of the Home are kept clean and staff follow procedures to prevent the spread of infection. The Manager must ensure all staff are suitably trained and qualified to carry out their role. The manager must ensure a method of checking, action and review is in place as a quality assurance system for the Home. Outstanding requirement x 4 01/03/07 7 OP26 13.3 01/03/07 8 OP28 18.1 a 01/05/07 9 OP33 24.1 a,b 01/03/07 10 OP38 13.4 a The Manager must ensure all 01/02/07 cupboards that hold cleaning chemicals are locked at all times. The Manager must ensure all service records for all equipment in the Home is held on file and available for inspection. 01/03/07 11 OP38 23.2 c RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Mary`s Residential Home DS0000027467.V329520.R01.S.doc Version 5.2 Page 26 1 OP9 It is recommended that MAR chart medicine entries are highlighted to assist care staff in recognising medicines not supplied in MDS containers when selecting medicines for administration It is recommended that the number of MAR charts in use at any time is rationalised to assist in medicine administration. It is recommended that warfarin schedules are set out on the actual MAR charts as far forward as the next planned scheduled INR test It is recommended that the Home has items around the premises that will occupy and stimulate residents when the activities staff member is not on duty and that staff encourage residents to be involved with something other than sleeping in the chair or sat in a room with the television on yet no one watching. It is recommended that residents have the meals presented in vegetable dishes at the table so they can choose the amount of food they like on the plate and not just have it served up for them in the kitchen. It is recommended that the staffing rota is adjusted to ensure the service at weekends is no different to the service in the week. It is recommended that the personnel files continue to be updated to ensure all records are held within the Home. It is recommended that staff are offered training in the compiling of care plans and shown what a comprehensive care plan should contain. It is recommended that a safe system is introduced that allows a senior member of staff access to residents finances that include taking or depositing money over the weekends and bank holidays. 2 3 OP9 OP9 4 OP12 5 OP15 6 OP27 7 8 OP29 OP30 9 OP35 St Mary`s Residential Home DS0000027467.V329520.R01.S.doc Version 5.2 Page 27 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.V329520.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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